On 24 hours in A&E – a tale of media not medicine- a case study in BBC Scotland’s approach to ‘informing’ the voting public.

By stewartb – a long read

This post is prompted by a recent article on the BBC News website authored by two BBC Scotland journalists: ‘Scots NHS doctors: Rise in patients waiting 24 hours in A&E “shocking’’. (See https://www.bbc.co.uk/news/uk-scotland-67242402) That piece was about NHS Scotland: this post is about BBC Scotland and its reporting of NHS Scotland.

What follows offers an analysis of content and technique. It assesses the statistical information on which the article is based and – in keeping with one of the core ‘public service’ missions of TuS –  provides context and perspective, matters of importance which are as usual absent from BBC Scotland’s news and current affairs journalism. 

The ‘doctors’

Commenting on an increase in NHS Scotland patients spending at least 24 hours in A&E, the ‘Scots NHS doctors’ of the BBC headline is the singular Dr John-Paul Loughrey, vice president of the Royal College of Emergency Medicine (RCEM). 

Dr Loughrey is quoted saying: “24 hours in A&E belongs on TV, not in daily reality for patients and staff”.  He has a way with words but so too does his colleague, Dr Adrian Boyle, President of the RCEM. On 25 September 2023, to mark the launch of its ‘manifesto’ for the next General Election, the RCEM issued a press statement. In this Dr Boyle is quoted stating: ‘It really is the case that 24 Hours in A&E is no longer just a TV show – it is the shameful reality for hundreds of thousands of people – and it must not be allowed to continue.’ (See https://rcem.ac.uk/rcem-launches-election-manifesto/)

What readers may find noteworthy is that the ‘hundreds of thousands of people’ spending 24 hours in A&E that Dr Boyle refers to are patients of NHS England!  I couldn’t find an BBC News article reporting these ‘shameful’ revelations – anyone? Perhaps the RCEM’s Dr Loughrey has cultivated better access to the BBC than Dr Boyle. Perhaps BBC Scotland is more interested – for one reason or another – in this kind of story than its counterparts elsewhere in the Corporation? In any event, the similarity in these comments on ’24 hours in A&E’ makes a comparison of the RCEM’s data for Scotland and England simply too inviting for a TuS contributor to resist! More on this later.

Why this matters

There is no intention in what follows to deny that NHS Scotland is facing serious and sustained challenges. There is no intention to deny that the BBC and others in the mainstream media have a right to report this. The issue is about how they go about their business and why.

First some basic background. Scotland, its government in Edinburgh and its NHS do not function within a normal, fully independent nation-state distinct from the rUK. The blindingly obvious context is of a UK in which the NHS is facing serious and sustained challenges in each of the four nations – including notably in the one nation who’s government has ALL POWERS to effect the performance of the NHS for which it is directly responsible. Therefore comparisons of four nations’ services which reveal NHS Scotland’s relatively better (or worse) performance are relevant to voters but evidence of ‘better’ is effectively hidden from voters here by BBC Scotland and too many other mainstream media outlets that supposedly ‘serve’ the people of Scotland. 

The special significance her of the BBC though is that: (a) it claims a status of impartiality; whilst (ii) it sustains relentless negative framing about Scotland’s public services; and then reinforces this when (iii) it fails to provide context or perspective in its reporting of Scotland; and when (iv) it opts to politicise stories about public services in Scotland, including aggregating and amplifying the views of opposition politicians; although on the latter and more broadly (v) it appears to operate a quite different editorial approach in Scotland to the other nations.

Reporting the long waits

The BBC Scotland article has statistics on the number of patients spending 24 hours or more in A&E in Scotland furnished by the RCEM. It makes no mention of how the absolute number compares with the total number of A&E attendances. How common are these experiences, even nowadays? 

Reasonably, the article makes much of the rise in numbers spending 24 hours in A&E in Scotland over time, quoting a 250 times increase since 2019. Of course this is a telling and concerning statistic. Who across the UK is not concerned about the state of the NHS in the four nations? As we shall discover later, there is also a marked increase in the number of patients experiencing very long periods in A&E in the NHS elsewhere. NHS Scotland is not exceptional but it does need improvement: what may be exceptional is the way the BBC reports on this in Scotland! The multiplier is so large in Scotland because pre-pandemic, NHS Scotland had fewer long waits as a proportion of attendances than for example NHS England, and it still has.

To help justify the latter comparison and for context, the graph below from the RCEM plots the number of 12 hour waits as a percentage of attendances in A&E from arrival to admission, transfer or discharge over the period January 2018 to January 2023. The much more favourable performance of NHS Scotland is clearly evident. Would voters in Scotland gain this insight from BBC Scotland? Are the BBC Scotland journalists so well connected with the RCEM aware of the latter’s work on comparative analysis?

The BBC Scotland article makes no attempt to explain why any or all of these patients spend such a long time in A&E – were there ever good or at least understandable clinical reasons or were they always associated with ‘NHS Scotland bad’ factors? Some voters reliant for their information on BBC Scotland’s reporting on NHS Scotland and the Scottish Government may by now be predisposed – dare I venture, ‘conditioned’ – into assuming the worst e.g. patients left endlessly on trolleys. 

As an aside, the significance of ‘trolley waits’ is a specific topic that the RCEM has long focused on, again in NHS England. Until earlier this year, the monthly releases of 12 hour waiting times performance data for NHS England measured waits NOT from arrival at A&E reception but from when a ‘decision to admit’ (DTA) was taken. In other words, whatever length of time was spent in A&E PRIOR to the DTA was NOT counted in. The RCEM called this ‘dishonest’ during an evidence session with a House of Lords committee: it has recently persuaded the UK health department and NHS England to alter this practice and come into line with NHS Scotland.

For perspective, an RCEM press statement dated 20 October, 2023 (available on its website) notes that in NHS England in July 2023 there were almost 24,000 people ‘waiting’ (in the strict sense of the word) over 12 hours in A&E from the decision to admit to admission. These are the so-called ‘trolley waits’. 

’24 hours in A&E’ – the data

The BBC Scotland article included data on the number of patients spending 24 hours or more in A&E. Supplied by the RCEM, these data came from Public Health Scotland through a Freedom of Information request.

We learn from BBC Scotland that:

• during Year 2022: c.7,000 patients spent at least 24 hours in A&E, an average of c.583 patients per month 

By sourcing Public Health Scotland data we know that:

• during Year 2022: there were c.1,318,807 attendances at major/Type 1 emergency departments in NHS Scotland
• therefore the percentage spending at least 24 hours in A&E = 0.53% (by calculation).

Consider the impact on this already small percentage if a proportion of lengthy waits could be ‘justified’ on clinical grounds or on other truly exceptional operational circumstances.

And from the same source:

• during January-June 2023: 3,949 patients spent at least 24 hours in A&E, an average of 658 per month.

Again from Public Health Scotland data we know that:

• during January-June 2023: there were c.565,003 attendances at major/Type 1 Emergency Departments in NHS Scotland
• therefore the percentage spending at least 24 hours in A&E = 0.69% (by calculation).

(To verify the above attendance numbers, see the spreadsheet downloadable from https://www.nhsperforms.scot/hospital-data/indicator-hospital?hospitalid=59&indicatorid=1 )

The statistical evidence for England taken from an RCEM source includes:

• between April 2022 and March 2023: 399,908 patients spent 24 hours or more in A&E in England i.e. averaging 33,325 patients per month.

Source: https://rcem.ac.uk/rcem-launches-election-manifesto/ 

The RCEM also published data on attendances and long stays acquired through a Freedom of Information request to NHS England – see table below.

Source https://res.cloudinary.com/studio-republic/images/v1695576169/RCEM_NHSE_FOI_24hr_Waits_Data_Set_Sept_2023/RCEM_NHSE_FOI_24hr_Waits_Data_Set_Sept_2023.pdf?_i=AA

In summary, the RCEM’s data for NHS England reveal:

• in the period April-December 2022: 281,369 patients spent at least 24 hours in A&E i.e. averaging 31,263 per month.

Using the RCEM’s tabulated data:

• in the period April-December 2022: there were 12,337,070 attendances at major/Type 1 Emergency Departments in NHS England
• therefore the percentage spending at least 24 hours = 2.28% (by calculation)

This compares with 0.53% spending 24 hours or more in A&E in NHS Scotland during 2022. The time periods overlap but are not the same: NHS Scotland’s performance statistic for the whole of 2022 covers parts of two winter periods. All in all, this is arguably a remarkable – an order of magnitude  – difference in the proportion of those experiencing 24 hour stays!  NHS Scotland – seemingly the only one held to account by the BBC over this metric – performs substantially better than its peer.

And more recently in NHS England:

• in the period January – March 2023: 118,539 patients spent at least 24 hours in A&E in NHS England i.e. averaging 32,513 per month.

Using the RCEM’s tabulated data:

• in the period January – March 2023: there were 3,834,717 attendances at major/Type 1 Emergency Departments in NHS England
• therefore the percentage spending at least 24 hours = 3.09% (by calculation).

The closest comparison with Scotland is the 0.69% experiencing 24 hours in A&E during the period January to June 2023. Yet again, an order of magnitude difference!

Candidly, the better performance by NHS Scotland on this metric should not be a surprise, except perhaps to those voters who rely on reports from BBC Scotland when making value judgements about Scotland, its health services and its government. 

For more on this see https://talkingupscotlandtwo.com/2023/10/26/royal-college-reveals-scotlands-far-better-wait-times/ 

The reporting technique

The BBC Scotland journalists failed to put the statistic on 24 hours or more spent in A&E in Scotland in the context of total A&E attendances. They failed to explain why any of the 24 hour stays occurred. And they failed (of course) to offer any perspective through peer to peer comparisons. All this builds on months if not years of reporting on NHS Scotland through the consistent use of negative frames and in a context-free and perspective-free void – unlike their colleagues in for example NHS Wales (for illustration see https://www.bbc.co.uk/news/uk-wales-67056279). Presumably the journalists, editors and producers working in BBC Wales wish to give their audience information in context and with perspective – all part of the public service in that country!

And after all the above, this BBC Scotland article entitled ‘Scots NHS doctors: Rise in patients waiting 24 hours in A&E ‘shocking’’’ devotes half of its lengthy content to the undoubtedly tragic story of one family and its personal opinion of the A&E services in Scotland. The BBC journalists report the remarks of a family member who ‘described every A&E trip as “absolutely terrifying” due to long wait times’.

What follows is not to deny an individual experience or individual tragedy. Rather it is to expose an underlying journalistic device designed to influence consumers of the news item. And the justification for calling out this device in this specific case is because it is being deployed – let’s not forget – by an organisation, BBC Scotland that for one reason or another opts to shun context and perspective in most of its reporting of Scotland. 

We see here the deployment of the ‘salient exemplar’. What follows comes from a 2017 article by Emily Dreyfuss, co-author of the book ‘Meme Wars: the Untold Stories of the Online Battles Upending Democracy in America’ based then in the Technology and Social Change team at Harvard University’s Shorenstein Center.

Source https://www.wired.com/2017/02/cognitive-bias-president-trump-understands-better/ 

Dreyfuss explains:

• ‘The human brain has a built-in tendency to conflate the aberrant with the norm. The news industry—and certain politicians—know this all too well’ – what linguist Professor George Lakoff has called the “salient exemplar”.

• psychologists identify a bias which they call the ‘availability heuristic’ which works the way memory works: ‘you judge the frequency, the probability, of something based on how easily you can bring it to mind’ and ‘Creating a vivid, salient image is a great way to make it memorable.’

• ‘Psychologists stress that your brain has to work this way, to a certain extent—otherwise you’d have a very hard time differentiating and prioritizing the avalanche of inputs you receive throughout your life’ – so its not a cognitive malfunction but it can be purposefully exploited.

So is there an inevitability to all this? Dreyfuss notes: ‘.. if you can’t totally eliminate your brain’s predisposition, you can at least work against the potential for bias it creates by understanding that it exists.’

The article also quotes a researcher from the Nieman Foundation for Journalism at Harvard University referring to the first and successful presidential election campaign of Donald Trump: ‘By focusing on negative stories, the news helped to paint a picture of an America in need of “being made great again”, and adding that ‘reporters need to get smarter about covering the non-aberrant, to show that commonplace does not equal mundane. It may not be rare, but it’s reality.’ 

Regrettably, the situation in Scotland, the motivations of too many journalists it seems, is the reverse: reporting Scotland negatively including by emphasising the aberrant seems to be the intended objective. If BBC Scotland and the wider mainstream media which ‘serves’ Scotland even approached balance by also covering the ‘non-aberrant’ and with it the positives, the need for TuS would be diminished!

End notes

Who wants to spend 24 hours in A&E, or 12 hours or eight or even four? Who wants to be in A&E at all? In my limited experience of this NHS service when accompanying ill relatives, they were distressed at being there (of course) but glad to be in a place with medical expertise and care all around. Me? I just wanted them home again, better. And yes, the time spent waiting in A&E was viewed negatively by me too, the healthy one, partly because of wanting to know ‘results’, wanting to have my loved one home soonest, and candidly, because I’ve never been known for my patience anyway.

Distress may well be made worse, confidence in medical professionals and in NHS Scotland as an institution diminished, if patients, their friends and families are constantly hearing – without accompanying details of context or perspective – about this seemingly exceptionally ‘bad’ NHS Scotland from the public service broadcaster.   

We in Scotland are experiencing a combination of bias by omission, an emphasis on singular personal cases – the deployment of the ‘salient exemplar’, a distinctive editorial policy to politicise public services accompanied by the shunning of context or perspective – all from BBC Scotland. Put together, when does this turn a public service to inform and properly hold governments and state institutions to account into a malign influencer for political ends?