In her first speech to the RCP’s annual conference Medicine 2015; Delivering the Future Hospital, RCP president Professor Jane Dacre talked about the effect the crisis in A&E had on the rest of the hospital behind it, affecting patient care and physicians’ ability to provide high quality care for patients.
And what a year it’s been, what a Winter it’s been…
I can’t be alone in being grateful that there was no flu epidemic, and that the weather has been relatively kind to us. The overwhelming pressure of acute admissions led so many hospitals to declare major incident status, that if those two factors had been added to the mix we would have been scarily close to an NHS collapse.
As physicians, we do not have a specific metric or target recorded on the Trust Dashboard but we also struggle on a daily basis to cope with the inexorable rise in emergency admissions to the wards, which remain largely undocumented by the government or the media.
It is time to redress the balance and tell our story, the physicians’ story.
The crisis in A&E has an immediate effect on the acute medical units behind it, units that are run by physicians, and eventually, on the rest of the hospital, affecting our 30 different specialties, our procedure lists, our outpatient clinics. The effects also spread out into the wider community, affecting community services, primary care and social care.
A&E doctors measure the patient journey with a stopwatch, we physicians measure the patient journey with a calendar. A&E physicians measure hours, but we physicians measure days and months.
Patients admitted to hospital experience a ‘special NHS time’ as their spell in hospital stretches or slows with every new phase of care.
Their journey through A&E took a few hours, their time on AMU a couple of days, their care in a specialist ward more days and even weeks, and the time taken to organise complex discharge arrangements even more days and potentially weeks.
With most NHS Trusts acting near capacity, even a few more patients through the front door each day can lead to the oxymoron ‘over 100%’ bed occupancy’. As some patients transfer to AMU following A&E, AMU fills up until it can’t take any more patients, so we are forced to transfer the least sick patients whom we would have wanted to keep for another day, to another specialist ward, or home in order to free up beds. Is that in those patients’ best interest… I don’t think so.
The increase in patients coming through to the acute medical unit and other medical wards means that more physician time is needed for diagnosis, treatment and monitoring. The knock-on effect of that is cancelled outpatient clinics, reduced or cancelled time for teaching and education sessions, longer working hours, and healthcare staff being asked to do overtime or come in on days off to cover. What message does that send to those we are teaching? What message does that send to our staff? It says that they are low in our priority list.
Once the specialist wards are full of patients from AMU, patients are placed on any other ward where there is a spare bed - these include surgical beds, and obstetrics and gynaecology beds.
As the medical patients are now taking up surgical beds, non-urgent operations are postponed because there are no beds for surgical patients to recover, putting more pressure on the surgical departments. For patients this can lead to poorer care, as they are now in a ‘medically inappropriate’ or ‘medically sub-optimised’ bed, being looked after by staff with completely different sets of knowledge and skills. Patients in the ‘wrong’ ward do not improve as quickly as those being cared for by specialists, which means they may spend even more time in hospital, thus compounding the problem. In turn, we physicians, other doctors and specialist nurses on specialty wards are frustrated at having patients on our wards whose medical conditions are outside our specialty, and worried that we may not be providing the best care for them. And the post take ward rounds take forever, as we are travelling all over the hospital.
I am a rheumatologist. One of my longstanding patients was having a flare of her rheumatoid arthritis. She couldn’t get a GP appointment, she couldn’t get an out patient appointment, so she went to A&E and was admitted for 3 days, when all she needed was a joint injection, which would have taken five minutes if she had reached the right place… that is crazy.
And I know that this affects everyone – in a survey we did last year, before the winter crisis, 79% of you said that the time taken to discharge a patients who were medically well had a negative impact on providing effective care for other patients who were ill, and 40% - that’s two-in-five of you – said this had the biggest impact on your hospital’s ability to provide effective care.
So for a period of time over the Winter whole health systems were seizing up with too many patients, patients in the wrong beds for their medical condition, some of them not being cared for by the appropriate specialists, some not being able to be discharged, while people waiting to come to hospital for operations were told that there wasn’t a bed and their operation was cancelled. We had to cancel specialist clinics, we had to cancel teaching sessions. Sometimes we even had to cancel clinics on the day, and send people home.
That is our story, and the story of the medical patients we serve…
For more information or a copy of the full speech please contact Linda Cuthbertson, head of PR, by phone 0203 075 1254 / 0774 877 7919, or on email linda.cuthbertson@rcplondon.ac.uk.