Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter delves into the most pressing performance matters troubling system leaders and provides unrivalled insight into what they plan to do about them

“The number of individual patients attending emergency departments has barely risen in five years.”

That statement, made by an eminent emergency care expert at a recent HSJ summit, would surprise many members of the public, and likely many in the NHS as well. It certainly surprised me, especially with four hour waiting time performance hitting rock bottom in March.

It’s well known that a subset of the population – often older people and others with multiple long term conditions – account for a disproportionate amount of emergency attendances and admissions, and of NHS resources.

But does current policy and management take into account quite how much of an impact this group is having, or even know enough about this group? Or, is the system too obsessed with gawping at crude activity growth, while on the treadmill of treating each individual episode as it turns up at hospital doors?

Two experts now argue that the number of individuals attending emergency departments has in fact only risen very marginally, in line with population growth, over the last five years – far less sharply than the rises in attendances and admissions activity data would suggest.

Hamish Dibley and Matthew Cooke, both from Capgemini, say their extensive deep dive qualitative and quantitative analysis shows that activity rises are driven by a small cohort of patients they call “the vital few”. They found some individuals come into emergency departments up to 100 times a year.

The figures they uncovered about this group, which is estimated to comprise 5 per cent of the population, are remarkable. They estimate the group:

  • Is responsible for between 30 and 50 per cent of four hour breaches.
  • Accounts for up to 40 per cent of bed capacity taken up by emergency admissions.
  • Will consume up to 50 per cent of activity resource and 30 to 40 per cent of cost.

Mr Dibley said patient demand was “stable, repeatable and predictable”. He added: “NHS commissioners and providers suffer from what I call ‘activity obsession disorder’. they capture activity numbers and mistake this for patient demand.

“The current applied logic is that if activity increases, the demand also goes up. Well, this is wrong. Activity is not the same thing as demand, it is a consequential component.”

Instead of focusing on standardised pathways, a system should target the small “vital few” group, he argued.

Mr Dibley and Professor Cooke (a member of the NHS Improvement emergency care improvement programme and sage of the sector, as well as an adviser to Capgemini) looked at eight health economies with a mix of providers. Their work says common themes emerged which can be applied more widely – here’s an example from St George’s University Hospitals Foundation Trust:

  • Patient demand at the St George’s A&E is a “stable” 100,000 people per year, of which around a third are admitted.
  • The trust says it saw 143,000 patients in A&E in 2014-15. “What it should say was that they performed 143,000 activities on these 100,000 patients,” says Mr Dibley, who carried out the work at the trust in 2015-16.
  • 6,500 individual patients account for 20 per cent of attendances.
  • 1,000 of them use 8 per cent of the total activity and account for 14 per cent of costs.
  • 195 of these patients account for one-seventh of the total annual bed capacity of the trust.

Other experts I spoke to said the research made stark the need for service reform, but does not make it any more straightforward. 

King’s Fund policy director Richard Murray said: “The fact that a small number of patients take up a disproportionate amount of resources is well known, but these numbers starkly express how bad the problem is and the need for meaningful service reform.”

He said as much as possible of money secured from the government’s promised long term funding settlement should go on transformation rather than plugging existing holes, necessary though that is. “We need to allow the system to live up to its aspirations on population health and integrated care. But within the current system it’s incredibly difficult to see where people will have the headroom in terms of either staff or money to do that,” he added.

Nuffield Trust deputy director of research Sarah Scobie said: “It does not surprise me that the number of individuals attending A&Es has not gone up.

“I don’t think anyone would argue that a more patient centred approach to service design could deliver better outcomes. But developing the interventions to tackle these patients, some of which have incredibly complex needs, is a huge challenge. There are simply no silver bullets and you are dealing with incredibly complex patient needs.”