Analysis

Always winter, never Christmas in emergency departments

Last winter was the most difficult for emergency departments in England for more than a decade. With little let up over the summer, this one could be even worse.
Winter scenes

Last winter was the most difficult for emergency departments in England for more than a decade. With little let up over the summer, this one could be even worse.

So is the health service prepared? NHS England and NHS Improvement certainly believe they have been pulling out the stops to get the health service ready.

Plans have been circulated across the NHS, setting out the most comprehensive measures yet in terms of winter planning.

Evidence presented

While not formally published, details of the plans were revealed in evidence to the House of Commons Health Committee.

They included a range of measures from ordering pharmacies to stay open during key parts of the festive period, to asking hospitals to reduce elective activity

...

Last winter was the most difficult for emergency departments in England for more than a decade. With little let up over the summer, this one could be even worse.

So is the health service prepared? NHS England and NHS Improvement certainly believe they have been pulling out the stops to get the health service ready.

Christmas scenes
NHS winter plans are comprehensive, but is there the staff and
money to implement them? Picture: John Houlihan

Plans have been circulated across the NHS, setting out the most comprehensive measures yet in terms of winter planning.

Evidence presented

While not formally published, details of the plans were revealed in evidence to the House of Commons’ Health Committee.

They included a range of measures from ordering pharmacies to stay open during key parts of the festive period, to asking hospitals to reduce elective activity in the lead up to Christmas.

184,188

the number of days of delayed discharges in July, a record

They have also set out ‘good practice’ measures NHS England and NHS Improvement want the emergency care system to take.

These include streamlining at the front door by using other staff such as specialist nurses, geriatricians and GPs, and increasing the amount of clinical input into the NHS 111 helpline. It is also suggested that ‘discharge to assess’ is used where possible, so that patients are discharged as soon as they are ready with a team of nurses and health professionals sent to their home to assess need.

Pilot extension

The ambulance ‘dispatch on disposition’ scheme, which gives trusts more time to assess calls before targets need deadlines, is to be extended to all trusts after being piloted.

NHS England says new regional emergency department (ED) delivery boards, headed by senior primary care officials, hospitals and regulators, will work with hospitals to ensure they have arrangements in place to cope this winter.

A spokespersn says by ‘working together’ hospitals, GPs, social services and other parts of the healthcare system can help ensure the NHS is ‘fully prepared’.

Lifting pressures

Attempts have also been made to relieve the pressure on hospitals by the decision early in the year to scrap the fines hospitals face for missing the 4-hour emergency services target, along with the ones for cancer and routine operations.

But will this be enough? After all, the 4-hour emergency services target has not been met at all this year and delayed discharges reached record levels in July after a rise of a quarter in the past 12 months.

12

the number of consecutive months the 4-hour ED target has been missed

The Royal College of Nursing has given evidence to the Health Committee of EDs ‘buckling’ under the pressure and facing a ‘drastic shortage’ of nurses.

This problem – along with a lack of money – is the major hole in the plans, says RCN professional lead for acute, emergency and critical care Anna Crossley.

She says that while a lot of the initiatives being highlighted are making a difference where they are being used, money and staffing issues are ‘the two elephants in the room’ that will prevent the NHS from capitalising on them.

‘If we don’t have the staff there is a limit on what can be done – even if we know what works.’

She warns it is not just a problem with the emergency system as shortages are being seen in the community too.

Community shortages

Two recent reports from the King’s Fund illustrate this. In early September the think tank published a review of district nursing that warned workforce cuts had left nurses ‘exhausted’.

Later in the month a report on social care, produced with fellow think tank the Nuffield Trust, highlighted how the cuts in council care for older people – the numbers getting help have fallen by a quarter in the past 4 years – compounded pressures.

£120

the fine no longer to be levied when a patient has to wait for more than 4 hours in an ED

Independent nurse consultant Deborah Sturdy, nursing adviser for Care England, which represents providers, says it creates a ‘vicious circle’ where cuts to community nursing and the care sector result in rising hospital admissions.

‘It is all connected. You cannot see this in silos,’ she adds.

RCN emergency care association chair Janet Youd has her doubts too. ‘This summer has seen demand in excess of that usually seen in winter.

‘We will need increased bed capacity, particularly if it is a bad norovirus season. This is something I haven’t seen mentioned in the plan.’

If the plans do not work, Ms Youd fears for ED staff morale.

‘If we don’t recruit soon we will see increased attrition of the existing workforce.

‘Many simply cannot face another winter like last year. We must invest in the recruitment and education of the emergency care workforce and find incentives to attract them to the specialty.’

What the emergency care system is being asked to do

  • Place health staff in EDs, such as specialist nurses, geriatricians and GPs, to screen patients coming in the ‘front door’ and divert them where appropriate.
  • Increase the number of NHS 111 calls dealt with by clinicians, such as nurses. The goal is to increase the number by 50% although it is acknowledged that will not be reached this winter.
  • Look into using ‘discharge to assess’, freeing up hospital beds more quickly.
  • Extend the ‘dispatch on disposition’ pilot to all areas giving call centres up to an extra 3 minutes to triage calls – does not cover the most serious red one calls.
  • Improve ED waiting time performance against the 4-hour target in line with the trajectories set out by regulators in July – each trust has its own individual target. To help, fines for missing the 95% mark have been scrapped.

What the rest of the system is being asked to do

  • Roll out the Stay Well This Winter campaign across TV, radio and online along with poster advertising between October and December to encourage people to look after themselves, explain what help is available and highlight the need for at-risk. groups to get the flu jab, which includes children in Year 3 this year.
  • A national winter resilience room to be available once again supported by 4 regional rooms to take charge of co-ordinating services during periods of extreme pressure.
  • Pharmacies to stay open on Friday 23 and Saturday 24 December and Sunday 1 January for those contractors with core hours on Sundays.
  • Councils asked to increase the availability of social care staff at weekends and over the festive period.
  • Hospitals should reduce elective admitted activity and outpatient appointments before Christmas to create spare capacity.
  • Better promotion of GP services that are available during the festive period – it was felt that those that were available last winter were not properly advertised.

 

Source: NHS England/NHS Improvement 


Nick Evans is a freelance journalist

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