Time to reward A&E departments for waste reduction – Feb 2022
The pilot study at Northwick Park (Daily Mail 08/02/22) – placing a GP and a nurse outside their A&E to vet and ‘redirect’ walk in patients is a highly commendable effort, but raises some interesting and unanswered questions that should be put to the Government.
This group are, on their own initiative tackling a nationwide problem of unnecessary attendances at A&E departments. This impacts 132 Trusts hosting about 180 Type1 (major) A&E departments. This is an issue of ‘streaming’ – making sure each patient is seen in the most cost effective way.
The Mail article quite rightly points out that this represents millions wasted due to the difference in cost between A&E attendance and cheaper alternatives such as redirection to a GP, pharmacist, Urgent Treatment Centre or Ambulatory Emergency Care. We recently tried to calculate potential savings based on improved streaming. However we could find no definative reference for the price of an average ED visit. We found one figure produced by a group of Solicitors (£419) but were unable to find the cost of the other solutions.
Working out what the various options cost in order to quantify the NHS waste due to poor streaming is made very difficult by lack of definitive NHS figures. We have data which would allow us to do that, if only we had figures for the alternative costs. However it has been questioned whether individual Trusts would be financially motivated to introduce a better Med-Tech streaming method based on such data. The answer is probably not, since the outlay would not be directly linked to a reward. We also cannot answer how the cost of two alternative solutions like the Northwick Park experiment versus our own solution would compare. That needs to know how much the GP and Nurse on duty outside Northwick Park hospital are costing.
Trusts used to suffer a financial penalty (technically fund withholding) if they had more than a preset proportion of patients missing the well known 4-hour target. This motivated attempts to increase ED flow and reduce ED length of stay (ED-LOS) with the latter being a source of another problem – unnecessary over-night admissions. These are another source of waste since the cost of ED attendance + admission jumps from £419 to £722 an extra £303 for the cost of that admission. With this type of waste no-longer discouraged by a specific financial penalty, the benefits of more efficient systems are not so prominent. Trusts may not be incentivised to implement them.
The same goes for losses due to litigation. A&E recently overtook orthopedic surgery as the source of most litigation cases against trusts (obstetrics holds the record for highest value payouts). However this waste (estimated at £194 million based on 2019/20 NHS resolution figures) comes out of a different funding ‘silo’ so that an intrinsically safer way of assessing patients would have no cost advantage to each A&E department.
Finally, what about the cost of staff burnout amongst ED nurses? Making work conditions for ED nurses more acceptable has no financial reward. Yet the cost of ED nurse burnout is exceptionally high. It costs £50,000-£70,000 and 3 years to train a replacement nurse. As we reported in our March 21 Blog, Bloom et al reported poor usability for all 15 of the Electronic Patient Record systems used in UK. These systems are difficult for doctors and irritating and stressful for nurses. Poor EPR systems are a documented cause of burnout of ED physicians in the US. Again there is no motivation for improvement because the costs of staff burnout are not directly linked to rewards.
Med-Tech for Emergency departments has the capacity to ‘bake in’ more cost-effective, safer and less irksome systems. However even if we can get hold of figures to calculate how much waste our systems could potentially prevent, these financial arguments will fall on deaf ears unless the Government manages to build in rewards for waste elimination. The Government and the public (since it is our money) need to know the size of the A&E waste problem.
Help in quantifying the NHS losses and ICS costs associated with A&E services would be a good start. While the system is being re-engineered (with clinical commissioning groups being subsumed by Integrated Care Systems), we need a campaign to re-establish links between financial incentives to avoid waste in this ‘loss leader’ for Trusts. We need to challenge the Government to make sure penalties and rewards influence A&E services in ways that reduce these various types of waste.
Gillie Francis – Feb 2022