The emergency care target has been an intense political issue since 2001 and remains a problem to the present day. The complexity of the system reflects the numerous interventions and re-organisations that have taken place in the NHS to achieve the A&E target. Demand into A&E is increasing and patients presenting to A&E often have chronic, not emergency, conditions. Many of the infra- structure developments such as the relatively new 111 telephone assistance service, the GP out-of-hours services and minor injury units were implemented with the objective to reduce the demand on A&E and reduce the number of emergency admissions to hospital, thus reducing the overall cost of the emergency service to the tax payer. However, those patients initially given a low priority, particularly the elderly, have learnt to go straight to A&E if they are acutely ill. Nationally, the emergency target performance has been steadily declining for the last few years, resulting in frequent winter crises where the system appears to completely break down.

To look at the challenges faced by the Chief Executive of SWFT in meeting this target it is useful to take a longitu- dinal look at the trusts performance and the actions taken

to address issues. Figure 3 shows the A&E performance at the trust from April 2007 to the end of October 2013. The chart shows that the SWFT A&E hasnt been able to hit the 98 per cent target consistently, with a number of periods over time when the trust suffered significant drops in performance. In November 2008, performance dropped suddenly and dramatically and then recovered in the summer of 2009, only to fall again in November 2011 and thereafter deteriorated with worsening perfor- mance particularly in the winter periods.

The A&E performance was the one target that the trust was failing to meet, so the trust started a major improvement programme in April 2009. The perfor- mance drop in November 2008 was highly significant as A&E performance is a factor that can affect a hospitals achievement of Foundation Status. Senior managers consider the achievement of foundation status a key part of their strategy because of the advantages it provides in being able to raise their own capital for investment, the ability to reinvest surpluses and less central government interference. Hence delays to achieving the A&E target were delaying all their independent investment decisions.

At this time two other critical factors came to the attention of the executive.

The comparable mortality data was published for all hospi- tals in England, now called rate adjusted morality index (RAMI) and produced and published publically by the private company, Dr Foster. The death rates for all hospi- tals in England are compared statistically and are indexed so that the death rate for the average hospital is equal to 100. In June 2009, the executive and population of South Warwickshire learned that their hospitals mortality rate for emergency patients was considerably above the 100 average figure. Checks suggested this was not a coding problem.

WasthemortalityhighinWarwickduetothedelaysin the emergency care system? Were the delays due to a shortage of resources or the very inefficient processes that staff had unwittingly created over the years of practice?

A patients experience

In June 2009, a patient wrote to the hospital CEO with a detailed and factual account of his experience of being admitted with a serious emergency over the Easter bank holiday. The CEO invited the patient to talk to the clinical staff who had been involved in his care. As the patient explained what happened, a member of staff mapped what had happened to him. This value map showed that he lay in bed for ten days waiting for care which should have only taken 34 hours, a crucial part of his care was delayed for five days and he lost one third of his blood volume over this time which went unnoticed by the staff on the three wards between which he was moved. The doctors involved in the care were shocked by the story and after a period of discussion accepted the system had problems. The patient accepted the public apology by the A&E consultant (whose department had done an excellent job) on behalf of all the hospitals staff, there was agreement that the current system could not be

allowed to continue. This emotional event was exactly what was needed to ensure that the clinicians and managers engaged, perhaps unwillingly to start with, in addressing the delays in their system of care even though they still believed that the poor care and flow was due to a lack of resources not the internal working and scheduling of the hospital, which had been beautifully observed and monitored by the patient.

Crisis in September 2009

A&E performance suddenly deteriorated again in September 2009. No-one could understand why as demand was normal for the time of year. An improvement programme created fortnightly big room meetings in which clinicians and senior managers from organisations across the local health and social care system were encouraged to attend and learn about changes to the wider system (not just inside the acute hospital). For the first time they were given the opportunity to observe the impact of these changes on the South Warwickshires health and social care system performance.

At the October 2009 big room meeting, the public health doctors working for the CCG revealed that a local 40-bed community hospital in Alcester had been closed on 1 September 2009 in order to reduce the CCGs costs. The remaining residents had been transferred into other NHS community hospitals or into private residential nursing homes funded by the patients privately or through social services. Although this had been part of the CCGs strategy for many years, the focus of attention had been on implementation of the physical changes to the system and not the impact on the system as a whole. From the CCGs perspective, the closure of Alcesters community beds was a straightforward decision from a financial and strategic point of view. A typical hospital

Answer following question about the case: CASE STUDY Where should the beds go? Infrastructure planning in NHS England

1.Discussion of implementation plans and Identify missing information and assumptions you made while analyzing the case

WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND 120.00% % ARE attendances 100.00% who are discharged, 80.00% transferred or admitted within 4 60.00% hours of arriving at 40.00% ABE 20.00% 0.00% % seen in 4 hours Target 2007-04-08 2007-08-05 2007-12-02 2008-03-30 2008-07-27 2008-11-23 2009-03-22 2009-07-19 2009-11-15 2010-03-14 2010-07-11 2010-11-07 90-EO-ITOC 2011-07-03 2011-10-30 2012-02-26 2012-06-24 2012-10-21 2013-02-17 2013-06-16 2013-10-13 Week Figure 3 A&E performance in South Warwickshire NHS Foundation Trust Source: Paul Walley Kate Silvester, based on NHS cata. WHERE SHOULD THE BEDS GO? INFRASTRUCTURE PLANNING IN NHS ENGLAND 120.00% % ARE attendances 100.00% who are discharged, 80.00% transferred or admitted within 4 60.00% hours of arriving at 40.00% ABE 20.00% 0.00% % seen in 4 hours Target 2007-04-08 2007-08-05 2007-12-02 2008-03-30 2008-07-27 2008-11-23 2009-03-22 2009-07-19 2009-11-15 2010-03-14 2010-07-11 2010-11-07 90-EO-ITOC 2011-07-03 2011-10-30 2012-02-26 2012-06-24 2012-10-21 2013-02-17 2013-06-16 2013-10-13 Week Figure 3 A&E performance in South Warwickshire NHS Foundation Trust Source: Paul Walley Kate Silvester, based on NHS cata