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Accident or Emergency? The NHS Bandwagon

As someone recovering from surgery for prostate cancer I am the last person to beat up the NHS. I have nothing but praise for the commitment and dedication of the staff at Hereford Accident & Emergency Department who, in my recent experience, did their absolute best to care for patients in trying circumstances and I am truly grateful to them and to their colleagues at Cheltenham Urology where I ended up.

 

However, the “system” in which the A&E staff find themselves working leaves a lot to be desired. Aside from issues of demand and budgets that may be way over my head there seems to be an awful lot for a bear with a working knowledge of customer experience design and efficient queue management systems to say on the subject.

 

First – the controversial subject of measurement – “95% of patients will be admitted, discharged or transferred within 4 hours”.

 

Why should a man who hurt his foot seven days ago and then waits a week to visit A&E on the following Sunday be seen within four hours when he could have visited his own GP during that week?

 

What’s the process for qualifying need, to make sure that A&E is really dealing with emergencies? Why not, for instance, have one, two or three GPs (depending on demand) do the triage front of house? They could act as gatekeepers passing genuine emergencies through to A&E and for those requiring less urgent assistance, use an on line booking service to fix appointments for patients with their own GP. They might even be able to deal with “quick fixes” , say things taking less than 10 minutes themselves with any further follow up referred back to the patients own GP.

 

Perhaps rather than a simple “95% will be seen within four hours” target we could have three categories, red – who must be seen urgently, amber who need some non-urgent treatment today and green who can safely attend their own GP on a subsequent day.  A&E is a precious, scarce resource and as its beneficiaries, we patients have a duty to ensure that we only call on it in direst need and not merest whim. Equally, perhaps staff need to be tougher with us when we turn up there without a genuine emergency, pushing us back into the right channels and not allowing us to use A&E as an out of hours GP service.

 

Surprisingly, there was no obvious linkage between the telephone based “111” service and A&E. In consequence I was triaged once on the phone and then waited in A&E for 90 minutes to be triaged again as an urgent case. This was disappointing. In this omni-channel world should we not be eliminating duplicated effort? Could my check in and triage detail not have been passed from the call centre to Hereford A&E saving them administration time and warning them of my impending arrival?

 

And whose bright idea was it to assess A&E using the ubiquitous Net Promoter - “Would you recommend?” question?

 

Spectacularly inappropriate. Net Promoter only applies where I am spending my money with competing brands. Arriving at A&E means that I have run out of choices.

 

And has no one else read Daniel Kahneman? The behavioural pyschologists tell us that we remember an experience by reference to the peak and end states of that experience. The Government’s “nudge” department know this stuff backwards. C’mon fellas, what are you doing?

 

The thing is, that in A&E, provided we finally achieve the outcome we were looking for we are immensely tolerant of what happened along the way. Particularly when we have no choice.

 

In consequence the “Would you recommend?” question only produces a bunch of meaningless data  which adds nothing to the debate about processes and outcomes within A&E. Drop it now, its wasting taxpayer’s money.

 

Once I made it into the inner sanctum of A&E I was shocked by the lack of coordination between the two scarcest resources in the department – doctors and treatment rooms. Nurses wasted precious minutes negotiating with each other for treatment space whilst doctors coped as best as they could. I saw instances of patients being moved in succession in and out of treatment rooms as priorities shifted dynamically and with no treatment having taken place. In my case, a surgical registrar was summoned by pager no fewer than four times to help me only to have to return to her department because no treatment space was available in A&E. Not only was my treatment delayed but she had her productive time severely disrupted.

 

This lack of a “Maitre ‘D function” appears counter intuitive.  With everyone working flat out I estimate 10-15% of precious, qualified, staff time was being wasted through lack of orchestration.

 

Beyond all of the big discussions about future funding of the NHS, three things should be examined right now. The issue of targets and their relevance, the question of how scarce resource is orchestrated to make efficient and effective use of it and finally, the connectivity between the telephone based “111” service and the “face to face” resources in A&E.

 

The NHS is a fabulous and unique facility that we in the UK all benefit from. Rather than making it a political football, we need our best thinking applied to meeting its challenges constructively and proactively.