Crying in A&E

Earlier this month came a report from the BBC of a porter at Northern Ireland's biggest accident and emergency department, who said he was ‘fed up watching our nurses cry’ following problems in the unit. Staff declared a ‘major incident’ at Belfast's Royal Victoria Hospital in early January, due to a large backlog of patients at the A&E department which made the unit look like a ‘war zone’.

And this in a mild winter.

Elsewhere in the UK, the A&E system is creaking with shortages of clinical staff and waiting times beginning to creep up as we saw in the recent QualityWatch report. How might queues and associated poor outcomes for patients be reduced at no extra cost?

Can’t be done?

But it can. First, tend to the flow of patients within the hospital walls. Look at the Flow Cost Quality programme we supported in two trusts: South Warwickshire NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust. Well-known methods of lean, clinical systems improvement and the theory of constraints led to improvements in both trusts over a relatively short period. Crucially, frontline staff and patients were used to understand where the problems lay, find solutions and then capacity was matched with demand (read our piece in the HSJ for more details).

Of course these aren’t the only trusts to try these methods, but isn't it odd that they aren’t more widespread, given the risk to patients in A&E? In Scotland and Wales they seem to agree. As part of the 1,000 Lives Improvement initiative, all health boards in Wales are now taking part in a collaborative linked to more widespread training in diagnostic and improvement methods, as used in our Flow programme. Scotland is developing its own version – dubbed McFlow. While these are national initiatives, they are not ‘command’ but ‘bottom up’. This fine line is easy to stray over, and the task will be not to return to bad habits when the heat is on.

Second, clogging up of A&E is clearly not just an A&E problem, but a result of performance elsewhere – hence the push on integrated care. How to accelerate integrated care must be one of the most critical questions in healthcare across the OECD. There's a useful summary of international developments and evidence in this area by Dr Mark McClellan and others.

One route will be to modify the current set of national policies to make them more integration-friendly. Another will be for would-be integrators to look more closely at their local context, to understand what might unblock unhelpful cultures. If the external context is more the territory of the economists, the internal is more the terrain of the sociologists which is far more complex, less understood and often vaguely discussed as ‘leadership’. We'll soon be publishing some sunlight on ‘context’ in a series of thought papers, and another forthcoming report will synthesise how organisations might learn better to improve care.

Meantime all eyes in England are on how sites intend to use the Better Care Fund and how the 14 integrated care pioneers and other promising sites develop. My experience in helping select the pioneers last year showed there was no shortage of ideas, ‘mission’ or energy. The issue is more how to manage a complex intervention over a period of years, in a...er...challenging environment.

Constancy of purpose over time, among local leaders and policy makers will help, as will more rapid ways to learn from peers and practical support. On the latter, there will be a role for using tested improvement methods in sites linked to formative quantitative and qualitative real-time feedback to show progress and help sites course-correct. In this, the sites could be a unique test bed, of interest internationally.

All worth trying, which beats crying.

Jennifer is Chief Executive of the Health Foundation, www.twitter.com/JenniferTHF