Press Association
Analysis
Hospital staff are struggling to deal with winter pressures Latest figures show that waiting-time targets have been missed in every part of the UK, reports Nick Triggle THIS WINTER may be the worst that emergency department (ED) staff have experienced for a generation. The four‑hour waiting time operational standards are being missed across the UK and hospitals are reporting huge pressures on services. Some have even declared ‘major incidents’ in recent weeks, leading to elective operations being cancelled and staff being asked to help EDs cope with the demands. These demands have produced worrying results in the four nations of the UK, as the panel top right shows. England As the largest in the UK, England’s health service has dominated the headlines. Its performance over the last three months of 2014 produced the worst quarterly result since the four-hour operational standard was introduced ten years ago. In December, 92.6% of patients were managed within four hours, a figure significantly below the 95% threshold. Only one in 14 major ‘type 1’ units met the target, which means that about 90% of patients in these units were seen within four hours. 8
February 2015 | Volume 22 | Number 9
The pressure on EDs is affecting all parts of the hospital system, as a House of Commons Library report on the issue shows. The report, which was published last month, compares performance in EDs between November 3 and January 11 with that during the same period one and two years earlier. Results show that so far this winter: ■■ There were 202 ED diverts, an increase of 84% on 2013/14 and 7% on 2012/13. ■■ Ambulances experienced nearly 73,000 delays of more than 30 minutes, an increase of 71% on last year and of 23% on 2012/13. ■■ Delayed transfers of care made 178,500 beds unavailable, up 27% on last year and 55% the year before. ■■ Nearly 15,000 elective operations were cancelled, an increase of 39% on 2013/14 and of 55% on 2012/13. ■■ Nearly 500 patients waited more than 12 hours for admission to hospital, seven times more than in 2013/14 and 17 times more than in 2012/13. The experiences of hospital staff indicate how bad the situation has been.
Scarborough Hospital, part of the York Teaching Hospital NHS Foundation Trust, was one of those that declared a major incident in January. Lead nurse Simon Etches says the influx of patients and the shortage of available beds created unbelievable pressures. ‘I have never seen staff working so hard or emergency departments in this sort of situation,’ he said. Boston Pilgrim Hospital, Lincolnshire, was put on ‘black alert’ at one point. Deputy director of operations Tina White says the problems she experienced were the ‘worst in my 34 years in the NHS’. Health secretary Jeremy Hunt says he is aware that the pressures make caring for patients difficult for staff. ‘It is distressing when you have a lot of patients and you can’t give them the care that you want to give them,’ he says. But even though performance is at a historic low, he adds, it is still ‘better than any other country in the world that measures these things’. Northern Ireland Of the four UK countries, Northern Ireland performed worst in meeting the four-hour target. During December, just under 77% of patients in Northern Ireland were seen within four hours. At Antrim Area Hospital, part of the Northern Health and Social Care Trust, fewer than two thirds were. The pressures have continued into the new year, with hospitals having to take a series of emergency measures, including the cancelling of operations. Northern Health and Social Care Trust medical director Ken Lowry says that the December rise in patient numbers, at 4% from the previous month, took the service by surprise. ‘Unfortunately no one foresaw the extent of activity across Northern Ireland. We are seeing something we have never seen before,’ he says. RCN Northern Ireland deputy director Garrett Martin agrees the winter has been difficult. ‘Nurses are under a lot of pressure. They are doing the best they can, but it has been difficult and discharges are being delayed. The problems are compounded by the financial situation.’ EMERGENCY NURSE
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Analysis Health minister Jim Wells says there is ‘room for improvement’ but adds that, while the four-hour measure has not been achieved, there has been ‘improvement’ in the number of patients waiting more than 12 hours. In December, 92 patients waited this long compared with 125 the month before. Scotland What has been happening in Scotland is harder to establish. Relevant data are published there only quarterly, which means the most recent figures available concern ED performance in September. Data up to the end of 2014 are due to be released early this month, although interim figures already show winter has been difficult. These figures show that 93.5% of patients were seen, treated, admitted or discharged within four hours in all of Scotland’s EDs. This is below the nation’s target of 98%, which is higher than the 95% set elsewhere in the UK. In Scotland’s 13 ‘core’ EDs, 88.8% of patients were seen within four hours. This performance was slightly better than the 82.8% seen within four hours in England’s core EDs during the same period, something the Scottish Government was quick to point out in a statement it released to the media early in the new year. RCN Scotland director Theresa Fyffe says the figures should be seen in context, however. ‘Political point scoring is all well and good but it somewhat misses the point.
Percentage of patients seen within four hours Nation Target England 95 95 Northern Ireland Scotland 98 95 Wales
Result over one month All units Type 1 units 90.2 85.3 76.7 73.5 93.5* Unavailable 81.0 77.2
*Result for September 2014. All other results are for December that year
Wales Performance has dropped to record-low levels in Wales too. During December, 81% of patients were seen at all EDs within four hours, while the figure for ‘type 1’ units only was 77.2%. These figures represent the worst performance in Wales since 2009, when the current way of recording them was adopted. University Hospital of Wales lead nurse for emergency medicine Sharon O’Brien says her ED, the busiest in the country,
has often been ‘full 24/7’, adding: ‘We are seeing a huge increase in people who are acutely unwell.’ GP out-of-hours services have also reported their busiest winters ever. In the Abertawe Bro Morgannwg University Health Board area, the service received an unprecedented 1,800 calls on the weekend between Christmas and New Year. The Welsh Ambulance Service NHS Trust has also experienced high levels of demand. On New Year’s Day, for example, there were 725 category-A calls, 50% higher than what is considered a normal day and about 17% more than on the same day the previous year. Welsh College of Emergency Medicine chair Mark Poulden says these statistics show that there are pressures throughout the system. ‘We are seeing an increase in the number of sick patients with complex conditions,’ he says. ‘They spend longer in the emergency department because there is no space in the hospitals.’ Continued on page 10
found. Ministers allocated part of this sum to ambulance liaison officer posts, which are expected to speed up handovers between paramedics and emergency department staff. Many of those in charge of health services across the UK, maintain that the extra money has helped to relieve winter pressures. NHS England chief nursing officer Jane Cummings, for example, says it has paid for ‘extra beds, doctors and nurses’, and has expanded out-of-hospital services, including GP out-of-hours services. But others have their doubts. College of Emergency Medicine president Cliff Mann
says: ‘I am not sure this money has got through to the front line.’ He adds that the money was released too late to make a difference. Of the £700 million extra spending in England, for example, £300 million was not set aside until November. Wales did not receive its £40 million boost until last month. ‘This is far too late,’ says Dr Mann. ‘Hospitals need time to plan how they are going to use the money if they are to make the best use of it. We need a more sustainable and effective way of dealing with winter pressures than making last-minute hand outs.’
‘One of the reasons Scotland’s EDs have performed less badly than their counterparts in England is that patients’ surgery is being cancelled. Our concern should be about patient care not numbers.’ Health secretary Shona Robinson suggests that ministers are complacent. ‘It is clear we must improve our performance in winter and all year round, which is why we will go on increasing investment, improving systems and protecting staffing levels.’
Where has the money gone? This winter’s difficulties have arisen despite record sums of money being spent to prevent them. In England, the government set aside £700 million, or 75% more than in the previous year, to deal with healthcare problems. In Scotland, £28.2 million was made available to tackle problems in the health service, especially delayed discharges. Ministers in Wales allotted an extra £200 million to the health service, before topping it up with another £40 million specifically for the winter. In Northern Ireland, meanwhile, an additional £5 million was EMERGENCY NURSE
February 2015 | Volume 22 | Number 9
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9
Analysis What has caused the problems? to EDs, while others cite cuts to social care budgets. The most recent GP patient survey suggests that booking appointments with GPs is becoming more difficult, while analysis published last month by Age UK shows that the number of people aged over 65 receiving council-funded care has fallen by one fifth in three years even though the over-65 population has grown. Nuffield Trust chief executive Nigel Edwards thinks that all these factors, as well as serious staff recruitment and retention problem in EDs, are relevant. ‘We may be reaching the point at which general practice, and community and social care services can
no longer contain the growing demand for their services. The people concerned then turn up at hospital.’ Sheffield University professor of emergency medicine Suzanne Mason agrees. ‘Demand is increasing as patients decide to attend, and as patients are advised to attend by GPs and NHS 111. Meanwhile, clinical presentations are more complex and challenging. ‘Most hospital trusts run at high bed capacity, which makes [the management of patients] difficult when the system becomes busier than usual. The lack of community facilities leads to slower discharge processes, which in turn causes more crowding in EDs.’
Mr Poulden also says some patients wait ‘many, many hours’ in ambulances outside EDs. ‘They are in a relatively safe environment, but it is not an appropriate place to assess and treat them fully.’ Deputy health minister Vaughan Gething acknowledges that the winter is proving to be ‘extremely difficult’, with the highest number of attendances since 2009. ‘It is clear that all health services are experiencing significant pressures,’ he says, adding: ‘I would like to thank everyone in the Welsh NHS for their unrelenting commitment to patient care during this difficult period.’
The scale of the problems being experienced across the UK has prompted debate about how this winter compares with previous ones. RCN Emergency Care Association chair Janet Youd says: ‘This is the worst winter for a long time, probably since 2000. I remember working a late shift that year and returning the following day to see the same patients waiting. We had beds in corridors and ambulances backing up, and it is all being repeated this year. ‘Many emergency nurses have not experienced pressures like this, and they find it frustrating and difficult because
they cannot provide that psychological support patients need. ‘If an older patient has had a fall and broken her hip, for example, staff should be there to comfort her. But that is just not possible when the pressures are like they are. Such older patients are put in cubicles and left because their conditions are not life threatening.’ These problems have a political context too. With a general election only a few months away, opposition politicians have started to publicise them. In England, for example, shadow health secretary Andy Burnham has called for a summit to discuss what he calls a ‘crisis’ in emergency care. In Wales, Liberal Democrat leader Kirsty Williams has suggested that a cross-party commission should be set up to study how the health service can meet these ‘severe challenges’, while the Welsh Conservatives are claiming the Labour administration has run the health service ‘into the ground’. The coming months promise to be tricky, not only for those who work in the health service, but also for those in charge of it. See Board’s eye view, page 12
Press Association
The simple answer to this is that the number of people attending emergency departments (EDs) has risen by a huge amount. Data from NHS England show that, in 2014, there were more than 14.6 million visits to type 1 units. This represents a rise of more than 440,000 in one year, which far exceeds increases in previous years. There has been a similar unprecedented rise in recorded emergency admissions. A more difficult question is why are more people presenting to EDs? A number of answers have been proposed. Some commentators blame the NHS 111 telephone advice line for sending more patients
Nick Triggle is a freelance writer
Find out more
Addenbrooke’s Hospital, Cambridge, has declared a major incident this winter due to the pressure on emergency services
10 February 2015 | Volume 22 | Number 9
The House of Commons Library NHS winter pressures analysis can be accessed at tinyurl.com/k6nuz4y EMERGENCY NURSE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Analysis
Hospital staff are struggling to deal with winter pressures Latest figures show that waiting-time targets have been missed in every part of the UK, reports Nick Triggle THIS WINTER may be the worst that emergency department (ED) staff have experienced for a generation. The four‑hour waiting time operational standards are being missed across the UK and hospitals are reporting huge pressures on services. Some have even declared ‘major incidents’ in recent weeks, leading to elective operations being cancelled and staff being asked to help EDs cope with the demands. These demands have produced worrying results in the four nations of the UK, as the panel top right shows. England As the largest in the UK, England’s health service has dominated the headlines. Its performance over the last three months of 2014 produced the worst quarterly result since the four-hour operational standard was introduced ten years ago. In December, 92.6% of patients were managed within four hours, a figure significantly below the 95% threshold. Only one in 14 major ‘type 1’ units met the target, which means that about 90% of patients in these units were seen within four hours. 8
February 2015 | Volume 22 | Number 9
The pressure on EDs is affecting all parts of the hospital system, as a House of Commons Library report on the issue shows. The report, which was published last month, compares performance in EDs between November 3 and January 11 with that during the same period one and two years earlier. Results show that so far this winter: ■■ There were 202 ED diverts, an increase of 84% on 2013/14 and 7% on 2012/13. ■■ Ambulances experienced nearly 73,000 delays of more than 30 minutes, an increase of 71% on last year and of 23% on 2012/13. ■■ Delayed transfers of care made 178,500 beds unavailable, up 27% on last year and 55% the year before. ■■ Nearly 15,000 elective operations were cancelled, an increase of 39% on 2013/14 and of 55% on 2012/13. ■■ Nearly 500 patients waited more than 12 hours for admission to hospital, seven times more than in 2013/14 and 17 times more than in 2012/13. The experiences of hospital staff indicate how bad the situation has been.
Scarborough Hospital, part of the York Teaching Hospital NHS Foundation Trust, was one of those that declared a major incident in January. Lead nurse Simon Etches says the influx of patients and the shortage of available beds created unbelievable pressures. ‘I have never seen staff working so hard or emergency departments in this sort of situation,’ he said. Boston Pilgrim Hospital, Lincolnshire, was put on ‘black alert’ at one point. Deputy director of operations Tina White says the problems she experienced were the ‘worst in my 34 years in the NHS’. Health secretary Jeremy Hunt says he is aware that the pressures make caring for patients difficult for staff. ‘It is distressing when you have a lot of patients and you can’t give them the care that you want to give them,’ he says. But even though performance is at a historic low, he adds, it is still ‘better than any other country in the world that measures these things’. Northern Ireland Of the four UK countries, Northern Ireland performed worst in meeting the four-hour target. During December, just under 77% of patients in Northern Ireland were seen within four hours. At Antrim Area Hospital, part of the Northern Health and Social Care Trust, fewer than two thirds were. The pressures have continued into the new year, with hospitals having to take a series of emergency measures, including the cancelling of operations. Northern Health and Social Care Trust medical director Ken Lowry says that the December rise in patient numbers, at 4% from the previous month, took the service by surprise. ‘Unfortunately no one foresaw the extent of activity across Northern Ireland. We are seeing something we have never seen before,’ he says. RCN Northern Ireland deputy director Garrett Martin agrees the winter has been difficult. ‘Nurses are under a lot of pressure. They are doing the best they can, but it has been difficult and discharges are being delayed. The problems are compounded by the financial situation.’ EMERGENCY NURSE
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Analysis Health minister Jim Wells says there is ‘room for improvement’ but adds that, while the four-hour measure has not been achieved, there has been ‘improvement’ in the number of patients waiting more than 12 hours. In December, 92 patients waited this long compared with 125 the month before. Scotland What has been happening in Scotland is harder to establish. Relevant data are published there only quarterly, which means the most recent figures available concern ED performance in September. Data up to the end of 2014 are due to be released early this month, although interim figures already show winter has been difficult. These figures show that 93.5% of patients were seen, treated, admitted or discharged within four hours in all of Scotland’s EDs. This is below the nation’s target of 98%, which is higher than the 95% set elsewhere in the UK. In Scotland’s 13 ‘core’ EDs, 88.8% of patients were seen within four hours. This performance was slightly better than the 82.8% seen within four hours in England’s core EDs during the same period, something the Scottish Government was quick to point out in a statement it released to the media early in the new year. RCN Scotland director Theresa Fyffe says the figures should be seen in context, however. ‘Political point scoring is all well and good but it somewhat misses the point.
Percentage of patients seen within four hours Nation Target England 95 95 Northern Ireland Scotland 98 95 Wales
Result over one month All units Type 1 units 90.2 85.3 76.7 73.5 93.5* Unavailable 81.0 77.2
*Result for September 2014. All other results are for December that year
Wales Performance has dropped to record-low levels in Wales too. During December, 81% of patients were seen at all EDs within four hours, while the figure for ‘type 1’ units only was 77.2%. These figures represent the worst performance in Wales since 2009, when the current way of recording them was adopted. University Hospital of Wales lead nurse for emergency medicine Sharon O’Brien says her ED, the busiest in the country,
has often been ‘full 24/7’, adding: ‘We are seeing a huge increase in people who are acutely unwell.’ GP out-of-hours services have also reported their busiest winters ever. In the Abertawe Bro Morgannwg University Health Board area, the service received an unprecedented 1,800 calls on the weekend between Christmas and New Year. The Welsh Ambulance Service NHS Trust has also experienced high levels of demand. On New Year’s Day, for example, there were 725 category-A calls, 50% higher than what is considered a normal day and about 17% more than on the same day the previous year. Welsh College of Emergency Medicine chair Mark Poulden says these statistics show that there are pressures throughout the system. ‘We are seeing an increase in the number of sick patients with complex conditions,’ he says. ‘They spend longer in the emergency department because there is no space in the hospitals.’ Continued on page 10
found. Ministers allocated part of this sum to ambulance liaison officer posts, which are expected to speed up handovers between paramedics and emergency department staff. Many of those in charge of health services across the UK, maintain that the extra money has helped to relieve winter pressures. NHS England chief nursing officer Jane Cummings, for example, says it has paid for ‘extra beds, doctors and nurses’, and has expanded out-of-hospital services, including GP out-of-hours services. But others have their doubts. College of Emergency Medicine president Cliff Mann
says: ‘I am not sure this money has got through to the front line.’ He adds that the money was released too late to make a difference. Of the £700 million extra spending in England, for example, £300 million was not set aside until November. Wales did not receive its £40 million boost until last month. ‘This is far too late,’ says Dr Mann. ‘Hospitals need time to plan how they are going to use the money if they are to make the best use of it. We need a more sustainable and effective way of dealing with winter pressures than making last-minute hand outs.’
‘One of the reasons Scotland’s EDs have performed less badly than their counterparts in England is that patients’ surgery is being cancelled. Our concern should be about patient care not numbers.’ Health secretary Shona Robinson suggests that ministers are complacent. ‘It is clear we must improve our performance in winter and all year round, which is why we will go on increasing investment, improving systems and protecting staffing levels.’
Where has the money gone? This winter’s difficulties have arisen despite record sums of money being spent to prevent them. In England, the government set aside £700 million, or 75% more than in the previous year, to deal with healthcare problems. In Scotland, £28.2 million was made available to tackle problems in the health service, especially delayed discharges. Ministers in Wales allotted an extra £200 million to the health service, before topping it up with another £40 million specifically for the winter. In Northern Ireland, meanwhile, an additional £5 million was EMERGENCY NURSE
February 2015 | Volume 22 | Number 9
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9
Analysis What has caused the problems? to EDs, while others cite cuts to social care budgets. The most recent GP patient survey suggests that booking appointments with GPs is becoming more difficult, while analysis published last month by Age UK shows that the number of people aged over 65 receiving council-funded care has fallen by one fifth in three years even though the over-65 population has grown. Nuffield Trust chief executive Nigel Edwards thinks that all these factors, as well as serious staff recruitment and retention problem in EDs, are relevant. ‘We may be reaching the point at which general practice, and community and social care services can
no longer contain the growing demand for their services. The people concerned then turn up at hospital.’ Sheffield University professor of emergency medicine Suzanne Mason agrees. ‘Demand is increasing as patients decide to attend, and as patients are advised to attend by GPs and NHS 111. Meanwhile, clinical presentations are more complex and challenging. ‘Most hospital trusts run at high bed capacity, which makes [the management of patients] difficult when the system becomes busier than usual. The lack of community facilities leads to slower discharge processes, which in turn causes more crowding in EDs.’
Mr Poulden also says some patients wait ‘many, many hours’ in ambulances outside EDs. ‘They are in a relatively safe environment, but it is not an appropriate place to assess and treat them fully.’ Deputy health minister Vaughan Gething acknowledges that the winter is proving to be ‘extremely difficult’, with the highest number of attendances since 2009. ‘It is clear that all health services are experiencing significant pressures,’ he says, adding: ‘I would like to thank everyone in the Welsh NHS for their unrelenting commitment to patient care during this difficult period.’
The scale of the problems being experienced across the UK has prompted debate about how this winter compares with previous ones. RCN Emergency Care Association chair Janet Youd says: ‘This is the worst winter for a long time, probably since 2000. I remember working a late shift that year and returning the following day to see the same patients waiting. We had beds in corridors and ambulances backing up, and it is all being repeated this year. ‘Many emergency nurses have not experienced pressures like this, and they find it frustrating and difficult because
they cannot provide that psychological support patients need. ‘If an older patient has had a fall and broken her hip, for example, staff should be there to comfort her. But that is just not possible when the pressures are like they are. Such older patients are put in cubicles and left because their conditions are not life threatening.’ These problems have a political context too. With a general election only a few months away, opposition politicians have started to publicise them. In England, for example, shadow health secretary Andy Burnham has called for a summit to discuss what he calls a ‘crisis’ in emergency care. In Wales, Liberal Democrat leader Kirsty Williams has suggested that a cross-party commission should be set up to study how the health service can meet these ‘severe challenges’, while the Welsh Conservatives are claiming the Labour administration has run the health service ‘into the ground’. The coming months promise to be tricky, not only for those who work in the health service, but also for those in charge of it. See Board’s eye view, page 12
Press Association
The simple answer to this is that the number of people attending emergency departments (EDs) has risen by a huge amount. Data from NHS England show that, in 2014, there were more than 14.6 million visits to type 1 units. This represents a rise of more than 440,000 in one year, which far exceeds increases in previous years. There has been a similar unprecedented rise in recorded emergency admissions. A more difficult question is why are more people presenting to EDs? A number of answers have been proposed. Some commentators blame the NHS 111 telephone advice line for sending more patients
Nick Triggle is a freelance writer
Find out more
Addenbrooke’s Hospital, Cambridge, has declared a major incident this winter due to the pressure on emergency services
10 February 2015 | Volume 22 | Number 9
The House of Commons Library NHS winter pressures analysis can be accessed at tinyurl.com/k6nuz4y EMERGENCY NURSE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
