NHS in crisis: waiting times will only improve if we fix the whole system

The UK’s National Health Service is facing another winter of deferred treatments and longer waiting times as pressure from unscheduled care mounts. It’s a classic complex system management problem – but one we’ve tackled before

The announcement of an extended moratorium on non-urgent hospital operations, deferment of routine day-case and non-urgent appointments, and relaxation of other targets signals another winter of sustained pressure on the UK’s National Health Service (NHS) accident and emergency departments. Although senior NHS officials argue there is no crisis because the NHS has sufficient bed capacity to deal with rising demand, this is only the case if beds are freed by cancelling planned care.

For frontline staff and beleaguered hospital chief executives, not to mention patients facing postponed operations, debate about the definition of a ‘crisis’ means little. The real question is why unscheduled care – the unplanned, non-elective part of the healthcare system – is such a persistent problem.

The UK is not exceptional. Unscheduled care is a problem for hospitals around the world. This is partly because of the difficulties in integrating it with the rest of the care system to ensure a smooth flow of patients.

In the last budget, Chancellor Philip Hammond announced £100m for investment in accident and emergency departments. Measures include the introduction of more GPs in A&E departments, financial incentives for hitting A&E targets, and the appointment of a new national urgent and emergency care director for NHS England to oversee the programme.

For all the current debate and last year’s announcements by the chancellor, we seem to have forgotten that we have been here before

But questions remain over how these changes will be implemented. It is not clear what the urgent and emergency care director’s role will be or what powers they will have. The chancellor has been criticised for a failure to announce measures to keep people out of A&E in the first place. And the British Medical Association has argued GPs in A&E may have the effect of actually attracting more patients to hospitals.

Coping with unscheduled care is a classic complex system management problem, where unintended or unpredicted outcomes can arise from interventions to improve parts of a system. For instance, if you significantly reduce waiting times in A&E, but general practice has capacity problems and delays, patients may go to A&E rather than their GP, demand goes up and you eventually return to longer waits in A&E.

We know (in theory) how to better control the health system as a whole – we know that performance targets in different parts of the system create tensions which need to be minimised as far as possible, that the right kind of performance incentives should be put in place, that coordinated planning and delivery of services is needed to ensure seamless care is provided, that it is necessary to give authority to those responsible for coordination across boundaries, and that speeding the flow of patients in one subsystem can lead to blockages elsewhere.

Some of these principles are recognised in the recent initiatives. The financial incentives to improve A&E are designed to focus attention on A&E rather than other targets in elective care, at least until performance improves. Over the longer term, the trend towards greater integration of services should help address the problems arising from financial and organisational silos in different parts of the health system.

If you significantly reduce waiting times in A&E, but general practice has capacity problems and delays, patients may go to A&E rather than their GP

But for all the current debate and last year’s announcements by the chancellor, we seem to have forgotten that we have been here before. Whole system change to tackle A&E waiting times has been introduced previously, with some success – although this was not sustained.

The target – introduced in NHS England in 2002 – for hospitals to assess, treat and admit or discharge 98 per cent of patients arriving in A&E within four hours, helped reduce waiting times. However, as we hear almost daily in the media, we have gone backwards. The proportion of patients who are dealt with within the target (which was subsequently reduced to 95 per cent of patients) is now below where we were in 2002.

It’s a subject of debate exactly how much the current problems are due to cuts in resources, reductions in hospital beds, and the general pressure from an ageing population and rising demand. What is accepted, though, is that a truly ‘whole system’ perspective is needed if we are to return to acceptable waiting times in A&E.

It is timely to revisit the lessons from the past attempt to significantly improve unscheduled care in the NHS. About 10 years ago we researched the A&E improvement programme in Scotland, which delivered significantly better performance, at least initially.

In a recent paper in Organization Science, we went back to our data and the lessons from this programme for managing unscheduled care. In the paper, we highlight two key issues that need to be considered when designing whole system improvement programmes in healthcare:

1. Managing in a complex system

‘Complexity theory’ suggests the role of a manager in a complex system is to manage twin tensions: a ‘horizontal’ tension and a ‘vertical’ tension.

Managing horizontal tension means managers need to facilitate change within the boundaries of the system over which they have direct control, while also influencing and coordinating with the outside networks across boundaries. If the system is relatively ‘open’ (i.e. there are flows of information and resources across its boundaries) complexity theory tells us energy will inevitably be dissipated, so we need to ensure efforts for change are sustained.

The vertical tension for managers is between rules imposed from the top (i.e. the Department of Health and NHS leaders) and the need to stimulate actions for improvement by local hospital trusts and other bodies. This is all about ‘self-organisation’, ensuring the conditions are right for the effects of small improvement actions across organisational boundaries in the system to accumulate into wider improvements.

2. Time and organisation change

The other area to consider is time, measured either as duration, rate of change, frequency, delays, timing, or sequence. Time has a central place in the study of complex systems because of the possibility of delays. We can’t assume changes implemented within a system result in an observable impact immediately within the same system. If we zoom out to observe the wider system – perhaps a local health system rather than a single hospital – so does a system’s ‘order’, the number of interdependencies between different parts of the system. As the order grows, so does the likelihood of delay between the intervention and the response.

If we are to successfully make change across multiple levels, we need to ensure the timescales for intervening and observing changes are appropriate. So, making an organisational change in an individual department (such as A&E) might require us to observe its effects over a period of days or weeks. Changes at the level of an organisation as a whole (such as a hospital) might require observation over weeks or months. Changes across a whole system (the NHS or a region) will take place at a slower pace, so we may need to observe them over several months or longer.

For managers, a difficulty is therefore that corrective actions are often based on perceptions of the current dynamics of a system, which are themselves the lagged result of previousinterventions. Further attempts to correct that system – to tackle A&E delays, for instance – are influenced by the perceived discrepancy between the system’s current and targeted state and its rate of change, without taking into account the effect of previous changes to which the system is already responding. This can result in over-hasty correction, which may dissipate or reverse progress. Changes in a complex system often lead to a period of ‘worse before better’.

In our next article – published next Monday, 8 January – we will look in detail at Scotland’s Unscheduled Care Collaborative Programme, which introduced a ‘whole system’ perspective on improving A&E, and the lessons we can draw from it.