Lack of hospital beds causes emergency departments to miss targets
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39098.461968.DB (Published 18 January 2007) Cite this as: BMJ 2007;334:111
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The annual BMA survey of what some doctors think about A&E makes
great headlines but tells us little useful about what is happening in A&E
departments. The design is flawed in a way that would invalidate the
results of, for example, a clinical trial. We cannot, for example, compare
the results with the actual results submitted by trusts. We cannot trust
the results to be unbiased as those doctors annoyed with government policy
are probably more likely to respond. Nor can we test the results against
any of the more detailed surveys carried out by the Department of Health
in particular departments.
Perhaps the most serious concern relates to the reliability of
doctor's opinions. In the early days of A&E target the Department of
Health (and the Modernisation Agency) spent a lot of effort to find out in
detail what was happening in many departments by taking a complete week's
worth of patient journeys and analysing what happened and why delays were
caused. When the actual causes of delays were totted up (from
comprehensive patient-level data) they were frequently not what the A&E
staff expected. The top 4 or five causes of delay were mostly the same,
but the most important was frequently different to the staff's initial
impression. Since fixing the causes of undue delays requires you to know
what is actually happening, this implies that opinion is an unreliable
guide compared to actual comprehensively collected evidence.
Another problem with the report and the headlines based on it is a
confusion between symptoms and causes. Medics opinion that problems
getting people into beds from A&E is often a major problem is backed up by
detailed analysis. But the diagnosis that the problem is "not enough beds"
is plainly wrong.
It is nice to be able to blame someone else for your problems (in
this case the government or PCTs for not paying for more beds) but it is
better to analyse the real problem. If you look at when beds are needed
but not available--as we have done--the problem looks more like a lack of
coordination not an absolute shortage of beds. A&E's need for beds tends
to peak around or before lunchtime; typical hospitals discharge patients
much later in the afternoon. Hospitals who analyse the demand and
reorganise their discharge schedules can free up beds before the time of
day they are required creating plenty of headroom to deal with
emergencies. In striving for the headline about "not enough beds" an
important message--that the problem is fixable by better coordination
across the hospital--has been lost.
Competing interests:
Has worked on programmes related to delivering the A&E target.
Competing interests: No competing interests
The Need for Better Decision-Making
The Report of a National Survey of Emergency Medicine (the Report)
identified that 88 per cent of respondents identified a "lack of beds" as
a reason for emergency department access targets not being met. The health
system is a complex system and it is clear from the Report that a range of
reasons why access targets were not met exists. Leaving aside the issues
identified in the Report relating to the validity of the performance
statistics, it is evident that the issue of bed capacity was the main
reason for failing to meet access targets.
In recent years there has been much focus on the day-to-day
management of hospital beds, with the creation of patient flow managers,
increasing attention paid to day of surgery admission and discharge
planning. However, the need to improve strategic bed management planning
has failed to receive adequate attention.
If our telecommunication providers operated at the capacity of our
hospitals we would be faced with frequent telecommunication problems that
the community would likely deem unacceptable. Similarly, if our local
shops expected us to wait for interminably long periods, we'd move our
business. With health it's a bit harder - it's subject to various
Government and bureaucratic policy control, which includes the
introduction of targets, financial controls etc. All too often well-
meaning targets don't account for knock-on effects from elsewhere.
Emergency department access is clearly one of these - access to beds,
diagnostic service delay, discharge delay (which may be related to factors
outside of the control of a hospital or changes in funding) and staff
issues all clearly make this a complex topic. Add the financial
constraints that apply (that lead to bed closures as a mechanism for
saving dollars), and it's no wonder meeting targets can be challenging!
So how do we get better at management? There's no single solution!
Rather, adoption of scientific management techniques, such as bed
occupancy modelling or patient flow, which has been coined "Nosokinetics",
and the education of staff about such matters (or at least how to ask the
questions that will help them get to the bottom of their problems) would
be a good start. Understanding the impact of trying to win the
"performance measure" game would also be useful. This is not to say that
performance measures are not needed, rather it's about recognizing that
often performance measures result in conflicting behaviours and we need to
know which ones to chase. No single profession owns the solution: moving
forward can only occur if we agree to work together to improve the health
system.
For those wishing to learn more about some aspects of the management
science related to patient flow, we suggest you look at
www.nosokinetics.org.uk.
Mark Mackay
School of Psychology,
University of Adelaide
mark.mackay@psychology.adelaide.edu.au
Peter H. Millard
Visiting Professor
Health and Social Modelling Group,
Westminister University
phmillard@tiscali.co.uk
Competing interests:
None declared
Competing interests: No competing interests