Avoiding the Domino Effect

  |   MBI Perform

Domino-Effect-300x198Easter 2013 – the NHS launches its new 111 service under the slogan “Call 111 when it’s less urgent than 999”. However by the end of the weekend, patients in 30 areas were waiting more than 1 hour for a call back when it should have been within 10 minutes. Call abandonment rates were over 40% and Dr Laurence Buckman, chairman of the British Medical Association’s GP committee warned “The system appears to be rapidly melting down and we need action to stop patients being put at risk.”


In healthcare, everything is interrelated.  So when out-of-hours care is struggling the domino falls and guess what – emergency departments begin to fill up with patients who would have otherwise been managed through out-of-hours care. Fast forward to May 2013 and the Emergency College of Medicine says that emergency care is in “a crisis” with attendances rising faster than previous years. Chris Hopson, chief executive of the Foundation Trust Network which represents more than 200 health trusts in England, warned A&E services could collapse in six months: “A&E services have been under huge pressure, there is a danger the system will fall over in six months’ time unless we plan effectively for next winter,” he said.


The failure of 111 did not cause the A&E crisis – it was merely the straw that broke the camel’s back. However the surprising aspect of all of this has been the reactionary way the NHS and their political masters have responded. We will say it again for clarity –


“In healthcare, everything is interrelated.”


The failure of 111 should have set alarm bells ringing that emergency departments would very soon be under huge pressure – but it didn’t. And now the service is fire-fighting just to keep its head above water.


So where next? It’s obvious really. Emergency departments struggling, leads to more emergency admissions. More emergency admissions lead to fewer beds in the system. Fewer beds in the system lead to cancelling elective operations. Cancelling elective operations lead to failure to treat patients within the 18 week Referral to Treatment (RTT) time. The domino effect.


So what? Well, there is a view that these standards are pointless anyway, so who cares if patients end up waiting 3 months longer for their elective operation. We have three problems with this:

  1. Firstly, we have yet to encounter any condition where waiting longer  than 18 weeks is beneficial to the patient. To put it another way, the longer the patient waits, they more they suffer.
  2. Secondly, many people have a skewed view of elective operations, thinking they are not as serious as an emergency admission. However, in our experience there are many conditions that end up being admitted through emergency departments which are not as serious as the subsequent elective procedures that have to be cancelled as a result of the emergency admission taking up beds.
  3. Lastly, the government has a problem with 18 weeks. It is now law  that a patient has the right to be treated within 18 weeks. If Trusts become unable to meet this law – patients are entitled to go to a private institution paid for by – you guessed it – the NHS.


The domino effect has started – the chain reaction which leads to the failure to treat patients in 18 weeks is underway. Traditionally, the NHS has surplus beds in the summer months that it uses to push through more elective operations in the knowledge that at the height of winter, they will have to scale back elective operating. But this year, those surpluses do not exist. RTT needs to be a priority now. The NHS should be working on a 6 month capacity plan between now and Christmas and ensuring it is robust in terms of clinical management and scheduling.


“What is the NHS doing now in order to avoid the domino effect?”


MBI Health Group are specialist experts in RTT and clinical management. We will be providing regular updates on what the NHS should be doing about managing elective care over the next few weeks. Why not register with us to get our updates delivered direct to your inbox.