NHS crisis and “unstable” queuing system cannot be solved by Prime Minister’s creative thinking, as experts lay bare truth ahead of winter

Leading operations experts at Bayes Business School say that the pressure on the NHS is being exacerbated by problems including an “unstable” queuing system and have warned the Prime Minister to reconsider ‘creative thinking’ as a possible solution.

New NHS England data released yesterday shows that the UK’s public health system is under unprecedented levels of strain – with accident and emergency (A&E) waits and ambulance response times at their worst on record in the UK.

Bayes academics/experts say widespread reform is necessary for the system to function in the long term.

What is the problem?

NHS England said at the time it was facing a “tripledemic of Covid, flu and record pressure on emergency services” on Thursday 8 December.

While progress was made in reducing response times outside of London and a decrease in the number of people waiting more than 12 hours in A&E from a decision to admit to being committed, the latest data shows that:

• 7.2 million people were waiting to start routine treatment at the end of October, the highest since records began in August 2007.
• 556,307 people had to wait more than four hours before being admitted, transferred or discharged in November. The 95 per cent target hasn’t been met since 2015.
• 68.9 per cent of patients in England were seen within four hours in November, down from 69.3 per cent in October - the worst performance on record.
• An estimated 410,983 people in England have been waiting more than 52 weeks to start hospital treatment at the end of October.
• There was a slight fall in the numbers waiting more than 12 hours for a bed after a decision to admit – but the figure of 37,837 was still the second highest since records began.

Why is it happening?

Dr Navid Izady works closely in the modelling of healthcare service and manufacturing operations.

Dr Izady says the entire health system can be thought of as a network of queues, with ambulance services, A&E departments, inpatient departments, and community care services as the major units in the network. He says delays occur because either; there is a temporary mismatch between demand and capacity, leading to potentially long but stable queues, or overall capacity is less than overall demand, leading to queues which grow indefinitely.

“The delays that we are observing in the NHS at the moment point more towards queues observed in unstable systems,” said Dr Izady. “The data I have seen suggest the system is either unstable or is working close to the capacity which also means queues are going to be very long. The temporary mismatches between demand and capacity may also play a part, especially in emergency departments and ambulance systems where time of day and day of week impact in patient arrival patterns are significant. It is worth noting that queues in one unit of the network could easily block arrivals from upstream units, causing delays across the whole network.”

Professor Les Mayhew is a researcher of long-term healthcare having formerly worked in the Department of Health and Social Security and has advised numerous health care providers in the past.

Professor Mayhew says the NHS target of seeing patients within four hours was never achievable, as evidenced in a 2007 study conducted with Dr David Smith.

“We found that A&E was meeting the then 95 per cent target in four hours by sleight of hand,” said Professor Mayhew, who labelled the target “a fallacy”.“The NHS had invented a sub-department of A&E called the Medical Assessment Unit which was just another part of A&E but waiting times in these units did not count towards the target.

“While a problem then was poor staff rostering, the problem now is that performance has fallen off a cliff edge because standing problems have not been addressed and there are even fewer treatment centres. Because A&E is essentially a queuing system - even small delays or blockages in the system can cause queues to explode which is what we see day in and day out.”

Professor Mayhew, who labelled NHS planning as short sighted, said the problem was being exacerbated by issues including closures, long waiting times to see a GP, older people remaining in hospital because of shortages in social care, winter pressures and increased morbidity caused by the ageing population. Currently, weaknesses in the system are being exacerbated by staffing problems, sickness absence, and a lack of integrated working between health and social services.

He added that keeping people away from A&E departments by prescribing care packages at home would be an effective way to combat hospital congestion, particularly among the elderly with general medical conditions. “This idea could be easily scaled up and is reminiscent of a previous idea of ‘a hospital bed at home’.”

Professor ManMohan Sodhi, a world-leader in operations and supply chain management at Bayes, says the current problems can be put down to “a failure of foresight and not poor planning”.

He said reasons behind the deterioration of the service include EU expansion, with a disproportionate number of people in England using A&E instead of regular GPs while they were settling down.

What can be done about it?

Last month, Prime Minister Rishi Sunak said the government was “thinking creatively about what new roles and capabilities we need in the healthcare workforce of the future” and urged the NHS to shed “conventional wisdom”. Professor Sodhi said such a course of action would be a mistake, and said he hoped it was not a step towards privatising the industry.

“Liz Truss also believed in thinking creatively and shedding ‘conventional wisdom’ when it came to the economy, so maybe we should be more circumspect,” he said. “We know there is a gradual but accelerating trend towards partially privatising the health system, and Britain now spends as much as the USA in out-of-pocket expenses as a percentage of GDP. One way to accelerate privatisation would be to limit resources for a highly stretched system. Those who can afford to do so will look for alternatives to the NHS.

“Whether this shift is unintended or ideologically driven, the PM’s ‘creative thinking’ about new roles in healthcare need not be about fixing the NHS but creating a parallel system, which could lead to even worse operational problems.”

Professor Sodhi has researched the reconstruction of A&E facilities from a strategic viewpoint based on the Keogh Report of 2013.

The report proposed ideas including large A&E facilities in urban centres with specialties, for example, a section devoted only to geriatric patients, and having more and smaller A&E departments for minor injuries.

“The recommendations make sense and should be carried out,” said Professor Sodhi. “We looked at having separate A&E for geriatric patients and having separate facilities to treat drunk patients on weekends and both make sense. Another solution could be to create more facilities to deal with minor injuries, treatable by a nurse – about 40 per cent of patients could have been treated by a nurse and not a doctor – or even at a Boots location.”

What is the short-term fix?

Dr Izady added that short-term solutions could come in several ways and has proposed these in research papers:

1. Better use of the inpatient bed capacity by organising inpatient services in an optimal manner. Dr Izady’s research proposes a methodology for finding the best configuration of inpatient services given a total number of beds. The results show that substantial improvements can be made by choosing the right configuration at the expense of some nurse cross-training.
2. Matching the staffing profiles in A&Es with demand. With staffing levels often peaking too late, meaning the queues build up, Dr Izady’s research on calculating the optimal staffing profile found substantial improvements can be achieved by increasing and decreasing staffing levels at the right time. The same principle applies to ambulances.
3. Making it easier for hospitals to use staff banks from other hospitals in a region. This would provide a larger pool of temporary staff available to each hospital. Dr Izady’s research finds that temporary nurses are likely to provide value especially when there is a lot of uncertainty in demand.
4. Putting a registrar or consultant at the front door of emergency department entrances. This can allow for the triage of patients upon arrival and direct them to the right place (including sending them back home). Dr Izady simulated this scenario for a department in the past and labelled the results “very promising”
5. Currently, ambulances are typically sent to the closest hospital, meaning that one A&E department could get very busy while there is spare capacity in another one. Research shows that pooling facilities serving equal demand is likely to improve performance. This can be achieved to some extent by routing the ambulances to the hospital with lowest occupancy rather than the closest hospital.

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