Robert Royce analyses performance against the four hour A&E target since 2014-15 and shows that decline is not inevitable.
In 2014-15 (All Types) performance went below 95 per cent for the year (93.6 per cent) with Type 1 performance at 90.3 per cent. For the first three quarters of 2018-19 it has averaged 83 per cent and for All Types, 88.9 per cent. That figure will most likely drop again in quarter four given historical trends.
In quarter three for 2018-19 of 134 trusts, only four delivered 95 per cent (for Type 1) and only 10 delivered it for all types. In December, 66 trusts were under 80 per cent performance for Type 1 and of those, 21 were under 70 per cent and five under 60 per cent. There were also 280 12-hour breaches spread across 31 trusts.
In the last quarter of 2017-18 there were 2,276 12-hour breaches reported across 66 trusts. Despite the efforts made to avoid 12 hour breaches almost 50 per cent of acute trusts had them – the barely visible tip of a large iceberg of patients waiting a very long time for admission.
However, whilst many trusts position has deteriorated (some spectacularly so), a number of trusts have carried on delivering 90-95% (see table). Moreover some trusts have actually improved their performance on 2014/15 and got into the top 12 list.
Top 12 Trusts Type 1 (excluding Children’s)
[Note: where a trust has dropped out, or come into the table, previous/recent performance is in brackets]
| 2014-15 Qtr 3 | 2018-19 Qtr3 | ||
|---|---|---|---|
|
1.Luton & Dunstable Foundation Trust |
97.8% | 1. Luton & Dunstable FT | 97.2% |
| 2.Sheffield Children’s FT | 97.1% | 2.Yeovil FT | 97.2% (94.4%) |
| 3.Dorset County FT | 96.4% | 3. Barnsley FT | 96.5% (94.4%) |
| 4.Bedford | 95.9% (90.3%) | 4. Homerton | 94.9% |
| 5.Royal Devon & Exeter FT | 95.8% (86.2%) | 5. Basildon & Thurrock FT | 94.8% (93.7%) |
| 6. Ipswich | 95.7% | 6. South Warwickshire FT | 94.5% (91.9%) |
| 7. Chelsea & Westminster FT | 95.6% | 7. South Tees FT | 94.4% (89.9%) |
| 8. Royal Surrey FT | 95.6% (85.7%) | 8. South Tyneside FT | 94.3% (90.5%) |
| 9. James Paget FT | 95.5% (89.8%) | 9. Western Sussex FT | 93.7% (92.3%) |
| 10. Homerton FT | 95.4% | 10. Harrogate & District FT | 92.7% (94.7%) |
| 11.Chesterfield FT | 95.3% (85.9%) | 11. Chelsea & Westminster FT | 92.8% |
| 12. Airdale FT | 95.1% (89.8%) | 12. Sherwood Forest FT | 91.8% (83.9%) |
[Note: Ipswich is now part of East Suffolk and North Essex FT. Qtr 3 2018-19 was 90.6 per cent for Type 1 cases]
Bottom 12 Trusts Type 1 (excluding Children’s)
| 2014-15 Qtr 3 | 2018-19 Qtr 3 | ||
|---|---|---|---|
| 1. London North West | 68.8% (77%) | 1. United Lincolnshire | 59.5% (90%) |
| 2. UHNM | 70.5% (78.2%) | 2. Worcestershire | 60.4%(86.7%) |
| 3. Cambridge FT | 75.2% (80.6%) | 3. Croydon | 60.9% (87.6%) |
| 4. Portsmouth | 76.1% (72.5%) | 4. Nottingham | 61.2% (83.5%) |
| 5. BHRUT | 76.8% (70%) | 5. Shrews &Telford | 61.7% (86.8%) |
| 6. Hull & East Yorkshire | 77% (83.3%) | 6. Blackpool FT | 61.9% (89.2%) |
| 7. Medway FT | 79% (76.5%) | 7. Lancashire FT | 62.7% (89.7%) |
| 8. Univ Hosp Leicester | 80% (72.8%) | 8. The Hillingdon | 62.6% |
| 9. The Hillingdon | 80% | 9. Wirral FT 66% | (89.6%) |
| 10. Imperial | 80.5% (76.3%) | 10. Kings FT | 66.1% (84.2%) |
| 11. Southampton FT | 80.6% (85.5%) | 11. Stockport FT | 67.5% (89.7%) |
| 12. Brighton & Sussex | 81.9% (78.4%) | 12. Royal Liverpool | 68.5% (91.2%) |
The worst performers have greater volatility than the best in terms of percentage differences between years. For the most part it is not that the worst performing trusts have improved, but rather that other trusts performance have dropped faster and further.
Increased demand is one possible reason for performance issues. Across England for quarter 3, Type 1 attendances rose by 7.2 per cent in 2018-19 compared to 2014-15 and All Types were up 10.5 per cent. Emergency admissions have risen faster (those from ED rose by 18.7 per cent and Emergency Admissions overall by 16.7 per cent).
Have the top performers benefited from a lower demand and admission profile?
Providing an answer is complicated by the M&A’s a number of trusts have experienced between the years in question. In some cases there has also been a significant change in activity between Types 1 and 3. This can be illustrated by the fact that the bottom 12 trusts actually saw 15,493 less Type 1 patients in quarter 3 2018-19 than in 2014-15, but their All Types activity went up by 86,459 cases (18.7 per cent)!
Comparing admission rates to attendances is a statistic that should have some validity regardless of organisational changes. It highlights that the top 12 performers admit a significantly lower proportion of patients to attendances than the 12 bottom performers. The figures are:
| Type 1 admission % v Type 1 attends | 2014/18 Qtr 3 | 2018/19 Qtr 3 |
|---|---|---|
| Top 12 | 23.75% | 26.62% |
| Bottom 12 | 28.87% | 32.54% |
This becomes particularly stark when one looks at total emergency admissions compared that to Type 1 attends.
All emerg admissions % v Type 1 Attends 2014/15 Qtr3 2018/19 Qtr 3
Top 12 31.85% 33.52%
Bottom 12 41.94% 46.53%
| All emerg admissions % v Type 1 Attends | 2014/15 Qtr3 | 2018/19 Qtr 3 |
|---|---|---|
| Top 12 | 31.85% | 33.52% |
| Bottom 12 | 41.94% | 46.53% |
Poorly performing trusts have a greater propensity to admit patients for whatever reason – lack of alternatives, risk aversion, breach avoidance etc. Despite the rise in demand the biggest problem hospitals face continues to be “Access Block” (an inability to admit patients because there are no beds available which leads to the “silting up” of ED with no room/clinical capacity to treat new patients). If a trust has a higher propensity to admit patients, then any “access block” issues will have a more severe effect.
It is easy to understand why many trusts are struggling, but why are some trusts maintaining high performance? This deserves a thorough analysis that goes well beyond soundbites about leadership and collaborative working. Some might object that the reasons are already well known, but if so, that begs even more questions.
The key point is that some trusts still achieve the target and moreover most of them are in parts of the country that you would not readily think of as “privileged”. Given that, we should refocus on what is required to deliver what was previously promised to the public, not redefine the target.
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