Analysis

Urgent care pressures force hospitals to declare major incidents

British Red Cross warning that the health service faced a ‘humanitarian crisis’
Ambulance

The first week of the year is always difficult for emergency departments (EDs), but this time was different. It was simply horrendous.

More than 40% of hospitals in England were forced to declare major incidents as bed shortages led to delays in EDs, thousands of trolley waits for beds and long queues of ambulances outside units. Even cancer operations, normally protected, were cancelled.

No region was left untouched. Data submitted to NHS Improvement as part of the daily reporting regime show just one trust hit the four-hour operational standard during the week with national performance slumping to below 78%.

65 out of 152

hospital trusts in England declared a major alert in first week of January 2017

The situation prompted the British Red

...

The first week of the year is always difficult for emergency departments (EDs), but this time was different. It was simply horrendous.

ED transportation
The British Red Cross has warned that the NHS faces a 'humanitarian crisis'
Picture: Science Photo Library

More than 40% of hospitals in England were forced to declare major incidents as bed shortages led to delays in EDs, thousands of trolley waits for beds and long queues of ambulances outside units. Even cancer operations, normally protected, were cancelled.

No region was left untouched. Data submitted to NHS Improvement as part of the daily reporting regime show just one trust hit the four-hour operational standard during the week with national performance slumping to below 78%.

65 out of 152

hospital trusts in England declared a major alert in first week of January 2017

The situation prompted the British Red Cross to warn that the health service was facing a ‘humanitarian crisis’.

Difficult

Pressures have since eased a little, but it looks almost certain that January will go down as the most difficult month for hospitals in England since the 1990s.

Other parts of the UK have not escaped either. In Northern Ireland and Wales, it is clear that care providers were in similar if not worse positions as 2017 got under way.

More than one third of patients in Northern Ireland were not admitted, transferred or discharged in four hours over Christmas, while in Wales during December one fifth waited longer than they should, with NHS Wales describing the pressures as ‘exceptional’.

63%

of patients were seen in four hours in Northern Ireland over the Christmas period

Scotland seems to have faired a little better. Its weekly data show performance hovering around 90% for much of the month.

'Worst ever'

Royal College of Nursing professional lead for acute, emergency and critical care Anna Crossley says members have been describing ED pressures as the ‘worst they’ve ever seen’.

‘That includes nurses who have worked in EDs for a long time,’ she says. ‘It has been so busy they haven’t been able to provide the quality of care they want to and that’s upsetting and damaging for morale as well as worrying for patients.

‘There is pressure to discharge patients before packages of care have been properly arranged and patients needing admission are waiting on trolleys and in corridors.’

England’s chief nursing officer Jane Cummings accepts it has been difficult, pointing out that the numbers coming to EDs are ‘some of the highest we’ve seen’.

She says nurse shortages in particular have made the situation worse, but is full of praise for how staff have gone the ‘extra mile’ and provided ‘fantastic care’ in the circumstances.

So what’s next? With plenty of winter left – last year March was the most difficult month – there is always the risk that pressures will escalate again.

But already thoughts are turning to how things should change. NHS Providers chief executive Chris Hopson says it was only the ‘heroic efforts’ of staff that warded off an even bigger crisis in the opening weeks of 2017.

2,425

patients in Wales had to spend more than 12 hours in the ED in December 2016 – a rise of two thirds on the same period the year before

He thinks there needs to be a national review into the planning process, whether dedicated winter funding is needed, the effects of staff shortages and what impact the pressures on GPs and social care are having.

Attention is also being given to whether the target should change in England. During the height of the pressures, health secretary Jeremy Hunt seemed to be paving the way for a rethink on the four-hour standard.

He told the House of Commons that 30% of people who go to EDs did not ‘need to be there’ and to protect the target ‘we need to be clear it’s a promise to sort out urgent health problems within four hours – not all health problems, however minor’.

While this was interpreted in some quarters as the end of the target, government and NHS officials have subsequently briefed that they are looking instead at ways to provide extra information about performance.

CASE STUDY: ‘I GOT HOME AND CRIED’

A sister, who wants to remain anonymous, recounts her experience in a large trauma centre at the start of January.

'I ran our major treatment area. Patients were waiting more than 12 hours for beds. My staff were broken and distressed. By the end of the day, you could see their care-worn, exhausted faces, feeling like they've failed. But really it's the government that has failed.’

That night she went home and cried, upset at being unable to help a 99-year-old woman off a trolley because there were no beds available.

‘At one point our treatment area, meant for 20 patients, had 56 patients crowded in corridors and around the nursing station. Our resus room built for six regularly had seven. Our waiting room didn't have enough seats for everyone.

‘We all keep going because what else can we do? Several times recently patients and relatives have asked staff if they're okay.

‘I've seen at least three members of staff hugged by relatives because they were so upset about their relatives being in corridors or in pain for too long.

‘Our compassion doesn't have a limit, but our energy and our ability to maintain our care does.’

Ambulance target changing

One target that is changing is the eight-minute target for ambulances to respond to urgent calls. Since 2015, pilot schemes have been looking at how to give call handlers extra time to decide whether to dispatch a crew to a red 2 call, the serious but not most immediately life-threatening cases.

Previously a decision had to be made in a minute, but that has been extended to four. Meanwhile, three areas are trialling a system that means most red 2 calls, including strokes, are not subject to the eight-minute target. A similar change in Wales saw a 90% reduction in eight-minute responses.

NHS England’s director for acute care Keith Willett, who is leading an urgent and emergency care review, says: ‘Too many ambulances are dispatched simply to hit target, with 25% stood down before they reach the scene.’

 

RCN emergency care association chair Janet Youd thinks it would be a mistake to ditch the target, describing it as ‘one of the best things that has happened’.

‘It’s a good barometer of the pressure on the whole system. You have to remember that in the 1990s it was just as bad as this, but apart from the odd case which hit the headlines it was difficult to quantify what was happening. That’s not the case this time.

‘But we have to remember it is not a measure of quality of care. You could have a hospital that has 98% compliance, but it might miss sepsis, signs of a heart attack or not give analgesia quickly enough, whereas hospital B might see only 70% in four hours but do all those things. Which would you rather go to?

‘We just need to measure the things that give a better idea about the quality as well.’


Nick Evans is a freelance health writer

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