Crisis, crisis. crisis ………

There are headlines in all the papers , on TV and social media about the difficulties in the NHS of coping with emergencies, ambulance services under strain , non emergency operations deferred to release hospital capacity – why is it so bad this year ?

Here are some reasons- there will be more .

Early January has always been a difficult time for hospitals to cope with emergency admissions. There have been 3 Bank Holidays , and the “slow ” days between Christmas and New Year when many routine services have been reduced- it is more difficult to discharge people who need community services or social care packages.  I remember the post Christmas period always being very tight for beds, because of the difficulty of discharging people home or accessing tests in a timely manner. But this year it is worse .

More people are attending A and E – is that because they cannot easily access other sources of help, such as general practice , or community mental health services ?

The number of older people and people with long term conditions is increasing, leading to increaseddemand.The number of admissions has gone up by 4.5% compared with last year.

Social care funding is tight, with local authority budgets having been cut by  up to 40%- leading to limited provision of care packages, increased eligibility criteria, and shortage of care home places as private providers withdraw from the market .

Busy A and E’s may delay accepting people from ambulances because of shortage of space- tying up ambulances in waiting at the entrance, rather than being available for call outs.

There is a skills shortage , particularly A and E medical staff and specialist nursing staff – reliance on locums is expensive and may lead to delayed decision making , as staff are less experienced  or may be working in an unfamiliar environment.

This year, there is virulent flu about, as well as a lot of respiratory infections . It is not a pandemic, but some people have become very ill, needing intensive care .

It’s easy to describe the problems  – what are the solutions, if any ? Because the situation is caused by a number of factors, there needs to be a variety of actions .

Hospitals have always used the beds ear marked for planned operations as overspill , to increase capacity . This has often meant people having their planned operations cancelled on the day , which is very distressing. The government solution is to avoid last minute cancellations by deferring non urgent ” operations for a month. This will release capacity – though stores up problems ahead trying to catch up- as well as causing distress to the poor person who has been deferred. To say nothing of the waste of capacity of the surgeons and theatre teams who have less to do .

If money was available, short term capacity could be purchased from the private sector- both hospitals and care homes .

We know that having  “clinical senior decision makers ” i.e. Consultants at the “front door ” means decisions are made more quickly – some admissions to hospital can be avoided , and other solutions found e.g. Urgent outpatients, community support , GP follow up.

The skills shortage in A and E  and the admitting wards will be addressed by longer term solutions – redeployment of numbers of staff in training to those emergency specialities ,  and a hard look at how many A and Es can be staffed . Individual hospitals could look at how staff are deployed – and move more staff to care for  the emergency patients .

Closer working between hospitals, social care and the voluntary sector may help with  discharges – this is about relationships, not structures, but adequate funding needs to be in place. Community health services – e.g. District nurses, also need to be adequately funded .

There needs to be a relentless drive in hospitals to make timely discharge of patients a priority . Although some of the block is caused by lack of provision in social care, some of it is caused by internal hospital processes . Patients not being reviewed at the weekends, no  discharge plan being made on admission, waiting for tests, slow decision making etc.

Theres no doubt that the NHS needs more money – as does social care . An emergency injection of cash now could mean more staff are pulled in to deal with the current situation and emergency capacity purchased .

We need longer term plans to increase workforce , and longer term plans for better working relationships and processes across the whole system. The current crisis in emergency care is not one of A and E departments but the whole system.

The politics of this will play out . The government does not want such headlines , so may be forced to release some more money. The danger is that this talk of crisis gives ammunition to those who claim the NHS cannot work , and who would prefer to move to an insurance system with private providers.

We need to call it how it is, but also remember that most patients  are receiving good care from hard working staff despite the circumstances . And to work towards longer term solutions , including lobbying for more resources to both local government and the NHS


Dr Linda Patterson

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