Tayside, Forth Valley and the truth behind their A&E stats

Almost one in 10 - 187 patients - spent longer than 12 hours in its ED.

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Meanwhile, at Ninewells, only five patients out of the 1,018 who attended waited any longer than eight hours - and none longer than 12. Overall, 87.4% of people were dealt with within four hours.

There is no doubt that Scotland's A&E services are under pressure like never before, but among the weekly deluge of miserable statistics is one consistent puzzle: exactly why does Tayside fare so well, and Forth Valley do so poorly? And is such a depiction even fair?

It is certainly true that Tayside tops the league table on ED turnover as far as mainland health boards go.

As recently as January it was exceeding 95% on the four-hour target, at a time when the national average had long since sunk below 80%.

Until recently, Ninewells hospital in Dundee was routinely exceeding 90% on the four-hour A&E target; Forth Valley Royal has struggled with the four-hour target and been regularly below 50 per cent since July (Image: PHS)

The region has two EDs (including the much smaller Perth Royal Infirmary unit), but it is Ninewells' unique - and arguably controversial - model which sets it apart.

On the one hand, since the mid-1990s it has adopted a very robust approach to triage.

"There was a very clear view that emergency medicine was emergency medicine and primary care was primary care," said Dr Neil Nichol, an emergency medicine consultant at Ninewells who retired in 2019.

"If you had a patient presenting with a big toe that had been sore for five days, our take would be 'not an emergency' - you ought to see a GP.

"That was enforced consistently, and we had a consultant there 24/7.

"The advantage of that was that all the nursing staff were aware of the policy, all of our junior doctors were aware of that policy, and a lot of our junior doctors went on to become GPs in the area so again, it became very well known throughout Tayside that this policy was in operation.

"So right at the start you're stopping people coming in and gumming up the system."

The more divisive element over the years has been Ninewells' adherence to a "continuous flow", or "North Bristol", model.

Under this approach, patients requiring admission are moved out of A&E as soon as they are ready, regardless of whether there are any beds available on wards.

If the hospital is full, this means patients who would have spent hours waiting on trolleys in A&E (to the detriment of the four-hour target) can end up spending hours on trolleys in the acute medical receiving unit instead. 

While they remain on a trolley they are still supposed to be included within the A&E statistics, but once moved to a bed - even if the acute receiving unit is running well over capacity - the four-hour A&E clock no longer applies.

This is popular with ED medics; less so with their acute physician colleagues who look after patients until they can be transferred onto specialist wards.

It has also been criticised by some for unfairly distorting Tayside's A&E performance.

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One NHS source familiar with the situation in Tayside said the Scottish Government had been reluctant to force the model on other regions amid fears of "potential hidden harm".

They said: "A trolley wait is a trolley wait. These patients end up queued up on trolleys outside the acute medical unit, so the emergency department can be relatively quiet but the acute medical unit can be running at 120-130% capacity and they'll still move patients from ED to there.

"No other hospital in the country has adopted that approach of moving patients from a near-empty ED into an overcrowded acute medical unit, but that's how they've managed to maintain high 80s, 90s on the four-hour target.

"But that's not reported in the data.

"It kind of put the Scottish Government in a difficult position because they were routinely meeting the standards and being held up as 'if Ninewells can do it', but the Government knew that there was all this hidden potential harm of patients on corridors, queueing outside the acute medical unit.

"Yes, there's good evidence that the longer patients wait in emergency departments - particularly with very long waits - the likelihood of harm increases.

"But there's no evidence that moving those patients from a trolley in the emergency department to a trolley outside the acute medical unit is beneficial.

"It's basically just moving the problem from one part of the hospital to another."

Dr Nichol acknowledges that the system was not universally popular, but noted other patient safety advantages - including speedier patient handovers from ambulances which gets vehicles back on the road faster to respond to new 999 calls.

"During the time that I was there, we never had an ambulance stack," said Dr Nichol.

"It is possible it's happened since then - but I would think it unlikely."

Dr Neil Nichol, who retired from Ninewells ED in 2019 (Image: NHS Tayside)

He also stressed that patients were never moved out of ED before they were ready.

He said: "If they were getting near the end of that [four-hour] time, assuming they were stable, then we would say to the [acute receiving] unit 'the patient is now coming up', because we are filling up, we're a busy unit, and we cannot continue to receive patients if we are full up.

"We wouldn't necessarily win a popularity contest with the acute physicians or surgeons, but before a patient was sent up to them they would be screened by a consultant to make sure they well enough and stable enough to go up.

"Our take was that we were emergency doctors, we do emergency work. We weren't manufacturing these patients. They existed, they needed specialist care, and we're getting them there quicker.

"It becomes the responsibility of the receiving unit to sort themselves out with a similar sort of system to decide who's an emergency and who should be seen first."

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Dr Nichol added that the Ninewells team felt they were viewed as "freakish and unusual outliers" by Government officials.

He said: "It may be an apocryphal tale, but I think it's true, that around eight years ago - when it was apparent that hospitals in Scotland were struggling with their EDs and their flow - apparently they sent a team of people off the New Zealand to see what they were doing. But nobody ever came to Tayside."

This goes some way to explaining why Tayside's A&E performance, on paper, far outstrips Forth Valley. But it's not the whole story.

Right now, the problems are threefold when it comes to bed waits for patients requiring admission from A&E.

Forth Valley Royal in Larbert (Image: PA)

One issue is that Forth Valley has fewer beds per head of population than comparable-sized health boards. For example, Borders General in Melrose has around one acute bed per 550 residents compared to one per 690 at Forth Valley Royal.

Inevitably, this exacerbates the second problem: that the hospital is "completely full".

"We've got something in the region of 500 acute beds and I think about 100 are full with delayed discharge patients at the moment," said one clinician, who asked not to be named.

"Each of our wards which is staffed for 32 patients has already gone up to 36 or 37.

"We've got patients in treatment rooms that aren't designed for overnight stays. We've got five patients in four-bedded bays.

"So when the emergency department is really busy we can't suddenly move an extra patient to each ward and create 10 or 12 beds at the front door.

"We are absolutely full. Our bed occupancy is something like 120 per cent."

The third issue is arguably the most contentious, and the one which really singles out Forth Valley: elective care.

Unusually, the health board took the decision to continue to prioritise scheduled care.

By the end of June this year, 55% of the 4,102 people on waiting lists in Forth Valley for a planned inpatient or day case procedure had been waiting less than 12 weeks.

By the end of June this year, there were 1,076 people on elective lists in Tayside who had been waiting for more than two years for an operation; in Forth Valley, the figure was just 24 (Image: PHS)

Only 24 (0.6%) had been waiting over two years compared to a national average of 7.2%. In Tayside, 1,076 patients - 9.2% of all those on its elective lists - had been waiting over two years.

The clinician said: "We're still running full elective surgery, we're still running as much as possible a normal outpatients service.

"There have been a number of conversations locally about whether we should switch off some of that elective performance to bolster staffing and resource at the front door, but there is a school of thought that if you can get on top of your elective workload then that will bail out the front door.

"The thinking is that you don't have people on long lists deteriorating in the community with heart failure or diabetes or inflammatory bowel disease or whatever it may be, and then having to be admitted as an emergency.

"There's not much evidence for that, but that's something people talk about: that if you can get on top of your elective workload and manage that, then that will relieve the pressure on the front door."