United Kingdom

More patients, fewer doctors – is the NHS facing a winter crisis?

 

The Guardian

 

A ward in a hospital© PA A ward in a hospital At Bradford Royal Infirmary’s A&E department, their usual 350 to 370 patients make a busy day. Several times this month, however, more than 400 patients have turned up in 24 hours, placing even greater strain on the hospital’s staff, beds and ability to cope.Last Saturday, they saw 414.That, staff say, is when busy becomes super-busy. But the way the numbers are creeping up, with more than 400 patients becoming a more frequent occurrence, super-busy could easily become their new norm, especially with winter just around the corner.

This rising demand is not unique to Bradford, says Helen Barker, the hospital’s chief operating officer. “Everybody’s finding it really difficult to deliver on the 95% target [the NHS-wide duty to treat 95% of A&E patients within four hours of their arrival].

“We are all seeing continued high attendances and a significantly high level of admissions too.” Those extra 50 or so patients make it very hard to ensure there are enough beds available for all who need them.

Usually the difficulties between November and March are followed by an easier spring and summer. But not any more. “We’ve not seen any reduction in patients arriving at A&E all year, really, so winter just feels like a 12-month phenomenon. We’ve not seen any let-up this year at all,” Barker adds. The numbers arriving at the hospital went up last winter from over 300 to more like 350 a day, and stayed up.

Why is this happening? She refers to “the acuity of patients” – medico-speak for how ill people are. Put simply, more patients are more unwell than before. “There’s an ever-growing demand from elderly patients. But we also have a lot of patients aged 35 to 60 who have breathing conditions, chest pains, heart problems, illnesses linked to their diet, such as obesity, which is causing diabetes, which leads to vascular disease, and includes those whose illness has been triggered by drinking too much, such as liver disease or malnutrition,” she adds.

Bradford is managing this better than most. Major efforts to hire extra staff and use of “virtual wards”, in which patients deemed well enough remain at home are cared for by visits from health professionals rather than in hospital all the time, mean the NHS trust is coping – at the moment – with the increased pressures.

Elsewhere in the NHS, though, A&E performance is so bad in a growing number of places that there is increasing fear of the kind of fullblown winter crisis not seen for many years. There is also acute concern inside the government that if the service visibly struggles to cope, it may pay a heavy political price at May’s general election.

Official NHS statistics underline why there is a growing belief that A&E is heading slowly, inexorably towards a midwinter meltdown. Hospital-based A&E units in England as a whole have missed the 95% target for the last 70 weeks running.

Despite mild late-autumn weather, performance in recent weeks has been worse than in the depths of last winter. Last week 13 A&Es did not manage to treat 80% of patients within four hours, up from nine the week before. The worst performer, University Hospitals of North Midlands, which runs hospitals in Stoke and Stafford, managed just 64.7%.

On 21 and 28 October, 23 patients at the trust had to wait on a trolley for more than 12 hours for a bed – something that should never happen – because of “very high levels of bed occupancy”.

Other A&E warning signs include the fact that last week also saw the highest number of patients ever admitted for treatment in England: 108,301. The same week also saw the largest number of patients forced to wait more than four hours for treatment, 30,102, which is just under twice as many as in the same week last year (15,708). And the number of patients waiting on a trolley for between four and 12 hours has more than doubled: 6,587 last week compared with 2,596 in the same week in 2013.

Growing numbers of hospitals are pleading with patients not to add to the pressure by turning up with minor problems, and to get help from their GP or a pharmacist, out of hours doctor or walk-in centre instead.

When Rotherham hospital did so two weeks ago, it explained it was “currently under extreme pressure, with a high volume of patients attending A&E”.

On Monday, Morriston hospital in Swansea became so busy that at one point 11 ambulances, each containing a patient, were forced to wait for up to three hours outside the A&E unit because there were too few beds available. This is the hospital where pensioner Sonia Powell died in the back of an ambulance in September when she too could not get inside. Doctors’ leaders in Wales are warning that emergency departments will be under “severe pressure” this winter because of an ongoing rise in the number of frail, elderly people needing care and a lack of beds.

On 13 November, Colchester hospital in Essex declared a major incident when inspectors from the Care Quality Commission found a host of concerns in its A&E unit and emergency assessment unit, especially staffing.

The hospital admits that its staff were overstretched and could not cope with the level of demand.

“If you look at where A&E performance in November was back in 2009 and 2010, we are probably already in a winter crisis,” says Richard Murray, the director of policy at the King’s Fund thinktank. “Performance against the four-hour target has already dipped well below where you’d expect it to be, with some hospitals failing to meet it and some missing the target by a long way. However, performance isn’t so bad that there’s a political crisis yet about hospitals not reaching the target.

“The winter crisis the politicians and people in the NHS really fear is when ambulances are redirected because hospitals can’t find a bed for the patients because they’ve run out of beds and so can’t admit them, and large numbers of patients are waiting on trolleys”, adds Murray. That’s what used to happen pretty much every winter and what might happen again this year, he said.

“What’s different now [to previous years] is that people aren’t confident the NHS would get through a very cold winter or a flu epidemic or a lot of people getting norovirus, a respiratory bug or the gastrointestinal bugs that close a lot of beds,” says Murray, who was until recently NHS England’s chief analyst.

“A&E performance is bad already, despite ministers putting a lot of extra winter funding into the NHS and despite all the usual risks – flu, norovirus and really cold weather – not being there.”

Dr Cliff Mann, the president of the College of Emergency Medicine, points out that 500 of the A&E doctors his organisation represents have relocated to Australia. As a result, the NHS has lost the capacity to see 750,000 patients a year at the same time as attendances have risen to 22m a year.

Will there be a winter crisis? “The ‘perfect storm’ of increased demand, in patient numbers, and reduced capacity, via lost doctors, means that performance is already less than this time last year,” says Mann. “When any system that cannot control demand is put under huge pressure, the first consequence is a reduction in quality and the next stage is a reduction in safety.”

Flu has not emerged as a problem yet, but norovirus is looking ominous. Public Health England says that so far this winter outbreaks of the winter vomiting bug have led to a hospital ward or bay being closed 125 times, more than double the number (60) in the same period last year. An outbreak earlier this month forced Royal Stoke hospital to seal off three wards, with 56 beds, for two weeks. That caused capacity problems even for a hospital boasting 1,214 beds.

“We are expecting the pressures to keep on building this winter,” says Mann. “Last year we were very fortunate that we had no flu and very little norovirus. But the number of hospitals already having to close wards because of norovirus, with the huge knock-on effect that has on emergency departments, and the bed shortages that affect all hospitals at some point in the week and some hospitals every day, mean this winter is going to be more challenging than the last one.”

Barker fears that much of the extra £700m the health secretary has given the NHS to help cope with winter will go on expensive agency staff to plug the gaps in rotas that affect almost every A&E unit. “Nursing agencies are offering nurses £1,000 for a weekend shift plus travel and accommodation. It just makes my blood boil. It’s the equivalent of paying for four nurses but only getting one,” she says.

One senior NHS figure says the £700m was “panic money”. To Murray, it shows that ministers are anxious about what winter might do to the NHS. “If I was Jeremy Hunt or David Cameron I’d be very worried that a fullblown, old-fashioned winter crisis is a real risk”, he says.

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