Analysis

Emergency in emergency care?

The RCN and Department of Health are among those to respond to Commons Health Committee inquiry into emergency care pressures.

The RCN and Department of Health are among those to respond to a Commons Health Committee inquiry into emergency care pressures

Each year, emergency care services brace themselves for so-called ‘winter pressures’, and the challenge of maintaining regular service in hospitals hits the headlines.

An increase in acutely unwell patients at this time of year – with a higher mortality rate than seen in other seasons – throws a spotlight on a system that many argue is at breaking point.

Plan of action evidence

Now, the RCN, along with the Department of Health (DH) and others, has submitted evidence to a Commons’ inquiry into planning for the winter pressures on emergency departments (EDs).

‘Across England, the acute sector is buckling under the strain of financial pressures and increased demand for services,’ writes the RCN.

‘It is clear that the pressure is affecting the whole system, however, [emergency departments] are often the place where the effects are most visible.’

The college draws attention to key areas of concern:

  • Staff shortages: recruitment and retention of nurses in the ED is poor – some operating on vacancy rates of between 10% and 20%.
  • Insufficient skill mix: with experienced nurses being replaced by lower band nurses.
  • Substantial financial investment in primary, community, social care and public health needed to ease pressure in EDs.
  • Action needed to support and improve workplace health and safety for ED nurses.
Nursing voice 

RCN professional lead for acute, emergency and critical care Anna Crossley says she welcomes the opportunity to provide the nursing voice to parliament but is cautious about predicting outcomes.

63,000

Number of patients seen on average each day in emergency departments in England 2015/16, while ambulances made 9,200 emergency journeys

‘What we would hope for would be long-term funding and investment, but in the current economic climate, I am not sure how likely that is going to be,’ she explains.

‘Our key concern is that there is a drastic shortage of nurses – and insufficient skill mix – in EDs.

‘The pressure on ED staff is unrelenting: it functions, but it does not function well.’

For the past five years, ED winter performance against the four-hour target has been in decline; an unwelcome trend that experts agree highlights a system in crisis.

Patients unable to be seen, transferred or discharged due to hospital overcrowding is an increasingly common feature.

In winter 2015/16, the four-hour target fell sharply and was missed for nearly one in five patients, according to recent analysis by NHS Improvement.

Funding fails to meet demands

Dartford and Gravesham NHS Trust has seen a deterioration in performance against the four-hour target in the past 12 months, according to its evidence to the inquiry.

‘We have found that the key driver for performance is bed occupancy – there is currently no funding available to increase the inpatient capacity to properly meet [the] demand.’

This winter the trust plans to convert office space to clinical space to provide additional capacity.

But many nurses believe terming the problem ‘winter pressures’ belittles the year-round strain on EDs.

Year round demand

RCN emergency nurse association chair Janet Youd says: ‘We now need to stop calling them "winter pressures", as the pressure is year round.’

Ms Crossley explains further: ‘The better term for it is “seasonal demand”.

1 November to 31 March
The period defined as ‘winter’. Evidence shows the majority of cold-related ill-health occurs at moderate outdoor winter temperatures of 4-8ºC

‘In reality more people attend emergency departments in summer, but more are admitted to hospital in winter and that is what causes problems.’

With cold weather arrives more cardiovascular and respiratory problems, and frail and vulnerable people, often with complex needs and multiple comorbidities, adds Ms Crossley. ‘These people are more likely to be unwell in winter and need a hospital bed.’

Problematically, the numbers of hospital admissions in winter can create bed blockages as patients in need of social care are unable to be discharged from beds, despite being medically fit.

‘People who come into the emergency department are then stuck there, not moving through the system’ says Ms Crossley.

Sandwell and West Birmingham Hospitals NHS Trust emergency nurse practitioner Jim Bethel says: ‘If there are no acute beds to admit people to, or nowhere to send people home to, it becomes problematic.’

Who's in control?

Mr Bethal says these capacity problems are part of a wider system issue, beyond the control of EDs.

27.9%

Percentage of patients admitted to hospitals as an emergency during winter, compared to 25.8% in summer

‘Where you have good capacity, systems do work and where you don’t, they fall down,’ he says.

‘I don’t think there is enough pressure put on ward managers to get patients home and see this as a hospital problem.

‘Hospitals look at it as an "emergency department problem" – there is not enough emphasis on what managers do to see it as a hospital problem.’

This sentiment is echoed by the Nuffield Trust in its inquiry evidence.

‘We recommend managers focus on faster discharge for patients with the longest stay in hospital,’ it writes.

‘It is also important that trusts improve their ability to manage and understand how patients flow through beds.’

The Health Committee will now examine the evidence and determine which steps need to be taken to ensure EDs can cope with the pressure they face in the coming winter.

Strain felt all year round

Pressures on EDs are not confined to winter.

Earlier this month, the ED at Grantham and District Hospital in Lincolnshire was temporarily closed at night because of concerns over high vacancy rates among junior doctors.

Last week, Wrightington, Wigan and Leigh NHS Foundation Trust urged the public to visit its ED only in a serious or life-threatening emergency as it was experiencing ‘extreme pressure’ on its emergency care system.

Director of operations Mary Fleming said: ‘Unnecessary attendances to our [ED] prevent doctors and nurses from seeing and treating those patients who need urgent care quickly.

‘It is putting a huge strain on the hospital as a whole.’

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