The Increasing Numbers
We need to understand why people misunderstand
Steve Black posted an interesting thread on Bluesky three days ago. He was pointing out yet another instance of healthcare managers saying that the pressure on the emergency care system is being caused by increasing numbers of A&E attendances. He noted that the increase in attendances has been confined almost exclusively to attendances for minor ailments at urgent treatment centres, and no such increase is happening at the major A&E departments where four-hour performance is at its most woeful. This misguided insistence on blaming increasing attendances proves that “if you don’t understand a problem (or deliberately misunderstand it to direct the blame elsewhere) then you can’t fix it”.
I agree with pretty much everything Steve Black is saying here, but I was bothered by the bit in brackets in that last quote. Yes, many NHS managers misunderstand the problem, but I don’t think they deliberately misunderstand the problem. And it’s incumbent on those of us who think we do understand the problem to try to understand why others don’t. At the risk of sounding a bit ‘meta’, we have to try to understand why managers misunderstand the problem. Because until we do, we’ll never be able to establish the right conditions to generate a more evidence-based understanding of the problem
When we try to make sense of emergency care, there is an overwhelming tendency for System 1 thinking to win over System 2 thinking. If we want to know why an A&E department is overcrowded, the most immediate explanation – the one that feels instinctively right - is that there’s been an increase in the number of A&E attendances. But this is hardly ever the right explanation. The more accurate explanation is that it’s been getting harder to admit patients from A&E into inpatient wards. These inpatient wards are fuller than they used to be, and their beds are occupied by patients who are harder to discharge or transfer than they were before. This is a counter-instinctive – System 2 - explanation because – for one thing - only about 30% of A&E attendances need to be admitted (so how come this minority are compromising the experience of everyone else?) and – for another - the source of the problem (the inpatient wards) is remote from where the problem is manifesting itself. There’s a bunch of other reasons, too: the inpatient wards are themselves experiencing exit block, for example, which means that the source of the problem is actually even more remote from A&E. But the key thing here is that System 1 thinking tends to trump System 2 thinking.
This misunderstanding persists because there aren’t enough people who understand the exit block cause-and-effect mechanism to challenge the dominant System 1 view. You’d think that the people with the data ought to be able to mount this challenge. After all, they are the people with the evidence to support the exit block argument. But data analysts can’t mount this challenge because they don’t have enough knowledge of how the urgent care system works to be able to compile and show the evidence. And in any case, they generally lack the standing or self-confidence to challenge the managers’ System 1 view.
And the System 1 explanation doesn’t just hold sway because it’s easy and instinctive; it also holds sway because it absolves managers of the responsibility for doing anything about it. If the problem is being caused by rising numbers of A&E attendances, then that means it’s likely being caused by deep-rooted systemic and societal forces: the failings of primary care, the ageing population, the fragmentation of neighbourhoods and communities. These are things that NHS managers cannot influence, which means they’re entitled to be fatalistic about the problem. The ‘increasing attendances’ diagnosis may not be the correct one, but it’s a diagnosis that excuses failure.
NHS managers want to control things – including four-hour performance. But four-hour performance is the manifestation of a bigger, more complex thing that is too big and too complex for System 1 thinking to grasp. The NHS’s analytical minds lack the knowledge and curiosity to find the answer and in any case are unable to make their voices heard. So managers are happy to consign it to the ‘beyond their control’ box in order for the world to make sense.