The Pressure Cooker

Saturday, August 6, 2016

About a year ago we looked back at the previous 10 years of NHS unscheduled care performance …

click here to read

… and warned that a catastrophe was on the way because we had created a urgent care “pressure cooker”.

Did waving the red warning flag make any difference?

It seems not.

The catastrophe happened just as predicted … A&E performance slumped to an all-time low, and has not recovered.


A pressure cooker is an elegantly simple system – a strong metal box with a sealed lid and a pressure-sensitive valve.  Food cooks more quickly at a higher temperature, and we can increase the boiling point of water by increasing the ambient pressure, so all we need to do is put some water in the cooker, close the lid, set the pressure limit we want (i.e. the temperature we want) and apply some heat.  Simple.  As the water boils the steam increases the pressure inside, until the regulator valve opens and lets a bit of steam out. The more heat we apply – the faster the steam comes out – but the internal pressure and temperature remain constant. An elegant self-regulating system.


Our unscheduled care acute hospital pressure cooker design is very similar – but it has an additional feature – we can squeeze raw patients in through a one-way valve labelled “admissions” and the internal pressure will squeeze them out through another one-way pressure-sensitive valve called “discharges”.

But there is not much head-space inside our hospital (i.e. empty beds) so pushing patients in will increase the pressure inside, and it will trigger an internal reaction called “fire-fighting” that generates heat (but sadly no insight).  When the internal pressure reaches the critical level, patients are squeezed out; ready-or-not.

What emerges from the chaotic cauldron is a mixture of under-cooked, just-right, and over-cooked patients.  And we then conduct quality control audits and we label what we find as “quality variation”, but it looks random so it gives us no clues as to what to do next.

Equilibrium is eventually achieved – what goes in comes out – the pressure and temperature auto-regulate – the chaos becomes chronic – and the quality of the output is predictably unpredictable, with some of it badly but randomly spoiled (i.e. harmed).

And our auto-regulating pressure cooker is very resistant to external influences, which after all is one of its key design features.


Squeezing a bit less in (i.e. admissions avoidance) does not make any difference to the internal pressure and temperature.  It auto-regulates.  The reduced flow means longer cooking time and we just get less under-cooked and more over-cooked output.  Oh, and we go bust because our revenue has reduced but our costs have not.

Building a bigger pressure cooker (i.e. adding more beds) does not make any sustained difference either.  Again the system auto-regulates.  The extra space allows a longer cooking time – and again we get less under-cooked and more over-cooked output.  Oh, and we still go bust (same revenue but increased cost).

Turning down the heat (i.e. reducing the 4 hr A&E lead time target yield from 98% to 95%) does not make any difference. Our elegant auto-regulating design adjusts itself to sustain the internal pressure and temperature.  Output is still variable, but least we do not go bust.


This metaphor may go some way to explain why the intuitively obvious “initiatives” to improve unscheduled care performance have had no significant or sustained impact.

And what is more worrying is that they may even have made the situation worse.

Working inside an urgent care pressure cooker is dangerous.  People get emotionally damaged and scarred.


The good news is that a different approach is available … a health and social care systems engineering (HSCSE) approach … one that we could use to change the fundamental design from fire-fighter to flow-facilitator.

Using HSCSE theory, techniques and tools we could specify, design, build, verify, implement and validate a low-pressure, low-resistance, low-wait, low-latency, high-efficiency unscheduled care flow design that is safe, timely, effective and affordable.

An emergency care “Dyson” so to speak.

But we are not training our people how to do that.

Why is that?


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