A&E Accident and Emergency

Our work in Healthcare is targeted at more effective planning and communication methods to the benefit of the patient and to manage or reduce cost without any reduction in front line services.. Nowhere is this more important than in Accident and Emergency Services in the NHS.

SYSTEM 21 staff have been working within the NHS UK for many years and have an excellent track record of results in A&E. When properly analysed and in order to improve the efficiency in A&E we find it necessary to have to make adjustments in the planning systems and work practices of some of the other Hospital areas that directly or indirectly impact on patient waiting times and breaches against target... We know where to look, what to change and how to go about it. SYSTEM 21 is able to specify and agree the necessary changes in the other parts of the Hospital that will generate the improvement in the patient experience in A&E and at the same time, regain control over cost..

Our most recent A&E Project Experience was in the following hospitals :

    Warrington & Halton Hospitals NHS Foundation Trust

    Salisbury NHS Foundation Trust

    Northumbria NHS Trust

    Gloucestershire Hospitals NHS Trust

The scope of our involvement in A&E has inevitably been targeted at the reduction in peak waiting times and to avoid breaches of Service guidelines. We have in every case been able to deliver a reduction in average waiting times and reduced breach rates, through the implementation of staff roster plan changes and other capacity planning solutions agreed with the A&E staff. In addition, we also work with clinicians to deliver operational adjustments, back up action for unplanned staff absence, alternative patient treatment options and the implementation of change in ancillary areas to increase capacity in the core A&E waiting areas.. For example, reductions in bed blocking from better discharge planning, improved porter availability, and short term volumetric forecasting techniques that increase the likelihood of having the right resource in the right place at the right time.

When we look at capacity planning and scheduling of staff in A&E, we have developed algorithms and planning methods that enable the service to be "more likely to cover the Service Requirement" at any given time.

The solutions included some or all of the following :

    Modelling of footfall data relative to nursing and clinical staffing rosters

    Review by area of rosters vs. activity

    Service design of MIU department to match footfall

    Introduction of enhanced KPI suite to manage the breach rule before it was too late

    Planning systems and management methods to increase bed availability for admissions

    Review of co-ordinator roles and responsibilities to enhance patient flow through the department

    Process rationalisation, mapping and improvement of departmental processes

    Optimised staff rostering linked across with other locations

    Management of consultant job plans

    Staff roster management and reporting systems that allow for action and reduced cost

    Capacity planning and scheduling of ancillary services such as portering

SYSTEM 21 is keen to help Accident and Emergency services make improvements that reduce waiting times and prevent breaches relative to operational targets. Another aim is to reduce the number of unnecessary admissions which add excess cost to the NHS.

We have a team of expert staff who can rapidly deliver this kind of change and transfer their skills to clinical and non clinical staff to continue the development of improvement initiatives long after our own involvement.

To assist with these objectives and to help Trusts identify where and when assistance is required, we publish below our findings from numerous analyses of A&E departments from locations all over the UK and not just from our experience in the hospitals listed above.

Our expertise can deliver solutions to these issues and our methodology engages A&E staff, both clinical and non clinical, in a participative approach to implement subtle changes that will increase control and the likelihood of having the appropriate resource available at the right time. Each A&E department has a different structure and not all these "issues" will be relevant to everyone. However, in our experience, most of these issues are present in some form or another and could be addressed individually or as a whole. If several of these issues are symptomatic of your own Trust, we would recommend a SYSTEM 21 review of current operations and a short project to deliver the benefits we know are possible to both patients and the Trust.

Using SYSTEM 21 to assist with this process will shorten the timescale to deliver the results and provide a dedicated resource while clinicians get on with their work.


1. Nursing and clinical rotas do not always match the predictable hourly, daily and seasonal footfall of the typical number of people present in the A&E department at any one time The ratio of capability is then exceeded, or wasted, at specific key times during each week, despite there being working statistical correlation of probability of the data that could be used for planning.

2. There is often an overlap of nurse staffing in the middle of the day (up to 2.5 hours).  This overlap time does not always get used for its intended purpose and there is a potential for wasted resource.

3. Staffing resource at the point of streaming often appear to be mismatched with attendance levels.  Errors at streaming result in patients being placed into the incorrect pathway, with a potential for an increase in admissions.  The feedback process when pathway errors are made has often been poor, making short term pathway "corrections" unlikely and longer term changes to procedure more difficult.

4. Resource at streaming is pulled into the department at peak times to assist with blocks upstream in the A&E system.  This then creates a backlog at the front of A&E resulting in extra pressure on breach target. We have found that this issue is nearly always linked to inadequate roster planning.

5. Staffing skill mix is often unintentionally excluded as a consideration in the staff roster planning process. This implies that the typical seniority / decision / prescribing ability of nursing staff is not always suitably matched to the number of A&E attendances anticipated.

6. There is often an obvious imbalance in staffing capacity and skills mix in senior nursing and consultant numbers relative to patient attendance rates over a 24 hour period. SYSTEM 21 consistently identify this as one of the main contributors of breaches when the two analyses are combined.

7. Formal rules relating to the booking and rostering of agency and locums staff, including the start times, number of shifts and end times are often lacking or inadequate. This issue is in itself is a significant contributor to A&E overspend and need not be if controlled correctly. Here again the key is an integrated forecast of patient numbers linked to the roster plans to ensure the "planning that is most likely to cover Service requirements."

8. The communication processes, procedures and contact between staff lack the control and simplicity of a well designed system. They nearly always need a review to rationalise the volume of administration activity relative to the communication objective. SYSTEM 21 has mapped out some very long and sometimes complicated communications processes and A&E procedures that added nothing to assist with communications or control over key issues. In effect they just added more time and delay in the process.

9. The length of response time by specialist on-call staff is often found to be too long. Patient pathways that have been reviewed consistently show a lack of staff ownership and communication of target timelines for defined next steps

10. Bookable outpatient slots are often not clearly known by staff in A&E. In some hospitals this route can often take serious pressure off patient waiting times when staff are absent or tied up with specific urgent cases.

11. In most hospital A&E departments we have reviewed, there was not found to be enough focus on the financial implications of admissions into the hospital by A&E staff.  Staff need better indicators of performance and there needs to be a focus on various alternative strategies that help to avoid a decision to admit, such as the increased use of available outpatient appointments , if the information was made available at the right point. However, most outpatient clinics cannot provide this information as they have planning and capacity issues of their own. (SEE OUTPATIENTS)

SYSTEM 21 has delivered solutions for all of the above issues in A&E in the NHS and although it does not prevent the relentless pressure at times on staff and services, the improvements mean fewer breaches, shorter waiting times and better "organisation" at all times. We aim to schedule the A&E resource so that is it "most likely to cover the service requirements at all times."

The above list is provided for illustration of issues in A&E. There are also change initiatives and improvements that can be made to planning systems and work methods in peripheral departments, to help improve the patient experience and measured service level performance in an A&E department.

Contact us for more information at info@system21.co.uk


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