by Gordon Miles FRCEM (Hon) MBA and Dr Simon Howes
For many years readers will have become familiar with the Winter headlines about the performance of the NHS healthcare systems across the UK. This Winter will be no different, unless of course it is even worse.
We are entering the Winter period with Emergency Departments across the UK under more stress than at any time in the last 15 years. That doesn’t auger well for the coming Winter; whether or not it is accompanied by an influenza and/or norovirus outbreak.
Work has been undertaken on some long-term solutions, which largely centre around an expansion of the medical workforce in Emergency Departments in England. However, in Scotland, Wales and Northern Ireland the Royal College of Emergency Medicine, continues to advocate for an effective workforce strategy that will deliver the trained staff required to deliver safe effective care for a growing and aging population. However, that is not to say we are alone in needing more workforce resources, clinical and nursing colleagues in other specialties are similarly placed and every Royal College in the UK is acutely aware of a shortage of trained staff.
Why is Winter so difficult?
To shine a torch into the morass of explanations about why Winter is so difficult, in 2015 the Royal College of Emergency Medicine launched the ‘Winter Flow Project’. Our aim was to highlight the difficulties facing an NHS struggling with unprecedented financial difficulties and insufficient resources. So why is Winter so difficult?
The Winter Flow Project seeks to find some answers to this question by looking at an area that our emergency physicians tell us is critical to timely care provision in Emergency Departments (ED): patient flow through the ED and into the hospital. The Winter Flow Project looks at patient flow within Emergency Departments and the hospitals in which they function, from the beginning of October until the end of March. It has been a great success because of the generosity of its contributors, with over 50 NHS Trusts and Health Boards from across the UK submitting data over a six-month period. This data has helped to provide a better understanding of system pressures and Four-Hour standard performance.
The findings have enabled the College to broaden the debate around Emergency Medicine beyond the usual narrow focus on the four-hour standard and meant that providers, commissioners, the national press and governments in each of the four nations of the UK were better informed about the challenges faced by staff working on the NHS frontline.
The project has proven invaluable and has now commenced data collection for its fourth year. As was the case in previous years, each participating Provider will submit weekly data on attendances, Four-Hour Standard performance, delayed transfers of care and cancelled elective operations. This data together better reflect pressures, constraints and consequences for system performance.
However, in an effort to reflect on-going difficulties in recruiting sufficient numbers of permanent staff, last year the project also asked its participating Providers how many locum and agency staff are working in their Emergency Departments. This additional fifth question is being retained for the coming year.
How does this Project work?
The data from individual Providers is aggregated to ensure the focus of consideration is the wider health care system rather than the performance of individual Trusts/Boards. Published on a Friday of the week following data collection, the summary data provide a current overview of ‘winter pressures’. The College is grateful to the participants who represent Trusts/Boards of all sizes and geographical locations.
Unlike NHS England datasets, there is no suggestion that our project represents a complete or permanent scrutiny of the healthcare system. Our data include all four countries of the UK though the majority of participating sites lie within England. It is just a sample of Trusts/Boards, albeit a large and representative one.
The data has proven to be of immense value and allows timely informed comment and analysis rather than just speculation. This would not be possible if we were to rely on the data sets published by NHS England, which – with the exception of the Winter Sitrep Data – is published significantly after the events they describe have actually taken place.
What happened during the 2017/2018 Winter?
In February 2018, NHS Improvement published its ‘Quarterly performance of the NHS provider sector: quarter 3 2017/18’. As the name suggests this gives an overview of NHS performance up to the end of December, and on the basis that four-hour standard performance at all ED facilities had only declined to 89.5% from 89.6%, this report declared that ‘the year-on-year decline in performance experienced during this period over the previous four years has halted.’
Looking at the Winter Flow Project data from the last three years can help set this statement in its proper context and helps us assess the extent to which it stands up to scrutiny. So what happened last Winter to provoke this College to call it as the worst Winter for a generation?
No matter how excellent the planning was, the service was under acute pressure, because plans without the resources to deliver them are likely to fail. Having a plan doesn’t fill rota gaps; emergency physicians take seven years to train so a quick fix isn’t possible. Similarly, increasing locum opportunities for the existing workforce only gets you so far as there is a limit to how many hours that can be worked by the existing workforce without fatigue compromising patient care.
Last Winter saw a continued deterioration in Four-Hour Standard performance across the UK and was the worst overall performance the Winter Flow Project has ever recorded. During the 2017-18 Winter Flow Project a total of 56 sites each contributed 26 consecutive 4-hour performance scores. The range of performance against the Four-Hour Standard was 49.13% to 99.47%, with an overall average of 81.21%.
Hospital systems improved the proportion of patients with Delayed Transfers of Care (DToC) compared to the previous winter, but this remained inadequate to cope with demand. For 51 Providers within Winter Flow the weekly DToC number increased from week one to a maximum over the 26 week period. In 32 Providers the increase in acute bed stock was greater than the highest point of the DToC increase. This means that those Providers were able to make additional bed capacity available notwithstanding the strain of increasing DToC cases.
However, 19 Providers were not able to increase the bed capacity to cover the spike in DToC cases and therefore, in certain weeks had no further capacity to accommodate the seasonal increase in admissions. This means that those Providers experienced a net loss in bed capacity in certain weeks despite their efforts to create additional capacity to meet seasonal demand.
The DToC rate is a surrogate marker of the increased numbers of patients who were medically optimised but unable to return to care in the community. This is a consequence on inadequate social care provision and exacerbates crowding in the hospital and the ED.
The total number of cancelled elective operations recorded by the Winter Flow group over the 26 week period was 88,509. This was higher than the numbers recorded by Winter Flow in the previous two years. The weekly number of cancellations recorded by Winter Flow in 2017-18 was 129% higher than 2015-16 (3410 /week compared to 1491/week). This was both bad news for those patients who were immediately affected and bad news for Providers whose income from elective work will have been restricted as a result.
The number of locum staff employed on the front-line increased by around 22% over the 26 weeks of the 2017-18 Winter Flow Project. This shows the lengths that Providers are willing to go to in order to maintain patient safety, but this also comes at a significant cost.
Given that this year’s Winter Flow Project recorded average Type 1 four-hour standard performance of 81.21% compared with 81.98% the previous year, to declare the year on year decline in Four-Hour Standard performance has been halted, might seem like a tempting conclusion. It would nonetheless be misguided.
While these figures might seem similar on a superficial level, a closer examination of the data indicates that the ability of Providers to see, treat, admit or discharge their patients has continued to deteriorate. Between January and March, the Winter Flow Project recorded average four-hour standard performance of 79.02%. This is the lowest quarterly score we have ever recorded. Moreover, it is 2.99 percentage points lower than in 2016-17 and 4.48 percentage points lower than was the case in in 2015-16. [See Figure 2]
The reality is that faced with attendances and admissions that have continued to rise — figures from NHS England indicate that attendances at Type 1 emergency departments have risen by 1.10% compared with Quarter 3 & 4 2016-17 and admissions have risen by 6.10% in the same period — NHS Providers did a remarkable job despite the fact that the resources provided to deliver the expected levels of service were ‘demonstrably’ inadequate1.
In this respect it is telling that in March 2018, when four-hour standard performance at Type 1 EDs was 76.4%, NHS England (while retaining their commitment to the Four-Hour Standard) effectively abandoned the idea of returning to 95% performance until 2020. Figure 3 Source: RCEM Winter Flow Project Final Report: May 2018
Why did it happen?
The College believes that there has been under investment in key areas of the NHS & Social Care that have impacted with increasing effect on urgent and emergency care systems in the UK. We estimate for example that there is a lack of at least 5,000 acute beds in hospitals in England alone.
Hospital systems are using a range of reactive levers including cancellation of elective care to try and manage the demand upon their systems. A number of other factors have also compromised the ability of flow and wider hospital system engagement to support Emergency Department function. The prolonged cold snap undoubtedly had an impact, despite the fact that planning for cold weather in winter is hardly unusual.
Our own evidence shows the lengths to which Providers have gone to try and support performance. Between January and March it appears that the Providers within the Winter Flow group responded to pressures by flexing2 their acute bed stock to a slightly greater extent than was the case last year, although this was far out stripped by increases in admissions.
Unfortunately, the situation was still more adverse in the wider NHS. NHS England data for both Quarter 3 and Quarter 4 shows that, as was the case in previous years, NHS Providers have tried to accommodate an ever-larger number of needy patients with an ever-diminishing bed base. The predictable result has been bed occupancy at record levels and thousands of patients stranded on trollies for more than 12 hours.
However, extra acute beds are only part of the answer: the real challenge comes in staffing those beds. There is a chronic shortage of doctors and nurses across all medical specialities, but this is particularly pronounced in Emergency Medicine. In addition, patterns of leave around the festive season and weather-related sickness for both patients and staff make a challenging situation even worse.
Improving the flow of patients from Emergency Departments into hospital and out into Social Care also has a crucial role to play in improving the situation. Some hospital systems do this much better than others. Good hospital systems proactively draw patients from the Emergency Department into wards once a decision to admit has been made. Poorer systems leave it to the emergency physicians to try to push the patients who need admission into the wards whilst simultaneously practising corridor medicine. Delivering care in corridors is at best undignified and at worst unsafe.
The fact that some hospitals manage patient crowding better than others points to the fact that wider hospital management can have an impact on this issue. This is why the Royal College of Emergency Medicine is currently developing guidance to help hospital boards consider these issues in the run up to the Winter period.
So what can be done?
There is a pressing need for clear and realistic planning that will optimise flow of patients from the Emergency Department and into the wider hospital, should they need admission. This also means that the secondary care sector (hospital Providers) must be given the resources to be able to do. Funding for social care - to address the needs of vulnerable patients who have been medically optimised and are otherwise fit to return home – needs to be improved after years of decline in both absolute and relative terms.
Systems must have a range of proactive and reactive steps in place to ensure patients flow, as well as wider engagement to maintain that flow. RCEM have made a number of recommendations in this area, for which see the College’s Vision 2020 Strategy3.
There is now a clear Emergency Department workforce strategy in England that must be fully implemented. The Devolved Governments of the UK must ensure a similar strategic focus to improve care delivery for patients within their different health systems.
As we have highlighted, NHS England data for both Quarter 3 and Quarter 4 2018-18 showed that, as was the case in previous years, NHS Providers have tried to accommodate an ever-larger number of needy patients with an ever-diminishing bed base. The predictable result has been bed occupancy at record levels and thousands of patients stranded on trollies for more than 12 hours.
However, a sustained effort to fill gaps in rotas by employing ever greater numbers of locum and agency staff show that Providers did not sit on their hands. It is also credit worthy that a determined drive to reduce the numbers of patients subject to Delayed Transfers of Care appears to have yielded results; albeit without reaching the 3.5% of bed stock mandated by the Secretary of State for Health and Social Care.
But there is still no getting away from the fact that throughout the Winter Flow reporting period this year, performance was supported by cancelling unprecedented numbers of elective operations. Between them, the contributing providers to this year’s project recorded an average of 3410 cancelled elective operations per week. While this may have helped to improve bed availability in a time of crisis, it is surely neither desirable or sustainable to support the standards of treatment for one group of patients directly at the expense of another group of patients. Particularly so because by denying those patients their planned elective treatment, you make it more likely – not less – that those same patients will arrive in an ED in need of more urgent medical help.
Many, of the practical steps to improve this situation have been highlighted to us by our contributing Providers. They have told us that a lack of social care provision consistently obstructs their ability to move medically optimised patients out of hospital. Similarly, a profound shortage of trained staff, and wider financial constraints have made opening additional acute beds problematic.
The Royal College of Emergency Medicine welcomes recent Government discussions about additional resources for the NHS. It is in the interests of both patients and staff that these discussions yield tangible results for emergency medicine as well as the wider system. The previous Secretary of State the Rt. Honourable Jeremy Hunt reiterated the Government’s commitment to returning four-hour standard performance to 95%. Our hospitals need the means to turn these aspirations into reality.
For more information on the College’s Winter Flow Project and to track how the system is coping with this coming Winter, visit the College website (www.rcem.ac.uk) using this shortened link for ease: https://bit.ly/2MTfgv1
Gordon Miles FRCEM (Hon) MBADr
Policy Manager References
2, Proactively managing their bed stock to meet patient demand.
3, RCEM Vision 2020 https://www.rcem.ac.uk/RCEM/Quality-Policy/Policy/ Vision_2020.aspx