More beds would ease crisis in A&E

The current crisis in emergency care has reminded me of my Florence Nightingale Scholarship study trip to Canada and the US in 1980.

Thirty-five years ago this year I had the opportunity to compare our emergency services with those across the Atlantic. While I discovered some amazing improvements that could be made in the UK – especially in trauma care, paramedic provision and nursing documentation – I was aware that one of the most appalling features of their emergency care services was the number of departments that were overcrowded and had patients waiting for in-patient beds.

The patients often spent up to 24 hours waiting in a department. The problem appeared to stem from a lack of in-patients beds compared with the volume of patients requiring admission.

Bearing in mind most hospitals in the US were run as a business, I was told that for economic reasons hospitals functioned with no spare bed capacity. I had never experienced anything like it because our hospitals always had spare bed capacity, so if a patient needed admission it happened without any delay.

In 1980 our hospital in Essex, like many other hospitals around the UK, had older patients waiting admission to nursing or care homes and other patient’s waiting discharge because no social services package was available. In fact, in 1980 there was no discharge planning until the medical staff decided the person was ready for discharge.

Also, unlike today, post-operative patients and those with long-term orthopaedic conditions spent much longer in hospital occupying beds. At the same time, all A&E departments had patients arriving that could and should have been to a GP or a chemist.

Many articles in Emergency Nurse Newsletter during the late 1980s and 1990s addressed the issue of what was often termed the ‘inappropriate attender’. Despite the similarities to today, emergency departments were not in crisis.

Fast forward to the late 1980s and 1990s and we see the move towards A&E closures – in Essex there were eight emergency departments and now there are five – and bed reductions on an unprecedented scale. Hundreds of beds lost and whole hospitals closed in the name of business efficiency, with no regard to the increasing population and the growth in the older population.

The advocates of such change argued that efficient discharge planning, as well as increasing the community and social care services, would offset the reductions. Yet, 25 years on, we are now seeing the results of the cart before the horse syndrome. Why close something before the other services are available?

Walk-in centres and minor injury units (MIU) have a place in the new emergency care system. Indeed, I was instrumental in opening the minor injuries unit in Thurrock in 1991. However, unless they are open for longer periods and have the support services available, they will never achieve their full potential (at the Thurrock MIU X-ray is still only available during weekdays, not at weekends).

Of course, early discharge planning and increased community care has ensured patients can be discharged earlier than in the 1980s. Combined with the major changes in surgery and the reduced length of hospital stay, it would appear that the closure of many beds may has been justified.

Now look at the current crisis. It is not due to a sudden surge in minor injuries; it is because the volume of really sick attenders is much higher than in 1980 and, in particular, the number of sick older patients has increased dramatically.

So, what is the solution? Of course we must continue to improve community provision and ensure appropriate discharge (I use the word appropriate wisely as many patients have been discharged early only to return to hospital sicker than when they left), but when the population has increased, when more people are sicker and need hospital admission, then the only way to ease the crisis is to increase the bed capacity.

Unfortunately, with the current shortage of nursing staff this will be difficult and will not happen overnight, but it should be included in any future emergency care plan.

Let’s see hospitals return to some degree of preparedness rather than this 100% occupancy day-in day-out. Perhaps one day, when advanced medical services and social care are available 24 hours in the community, and all support services run a seven-day service, and sick people that currently need admission can be cared for safely in the community, it may be time to reduce the bed numbers. However, until then, there should be a ward bed available for every patient that needs one, and without having to wait for hours.

About the author

Gary J Jones CBE is a nurse, and Fellow of the Royal College of Nursing, the Florence Nightingale Foundation, as well as an Honorary Fellow of the Faculty of Emergency Nursing.

Picture credit: Barney Newman