Much like the rest of the NHS, urgent and emergency care in England is in dire straits. Waiting times have soared, beds are scarce, wards are chronically understaffed and health workers are burnt out. This week, as nurses once again go on strike, paramedics, emergency care assistants, call handlers and physiotherapists will be doing the same at a number of trusts.
Recent analysis from the emergency doctors’ professional body, the Royal College of Emergency Medicine (RCEM) has found that people over the age of 80 are spending up to 16 hours in A&E waiting for care or a bed, nearly double the length of time they were waiting in 2021.
Over the past eight years conditions have deteriorated. Guidelines state that 95 per cent of patients who turn up at A&E should be discharged, admitted or transferred within four hours, but NHS England has not met this standard since July 2015. In December 2022 65 per cent of patients were seen within four hours – the lowest reported performance since data collection began.
“This is not how we want to practise medicine,” Adrian Boyle, president of the RCEM and an emergency medicine consultant, tells Spotlight. “And it’s not how we want to look after people who are worried, anxious, sick and injured.”
After a lull during lockdowns, there was a “vicious rebound” in admissions in 2022, he says, which drove emergency care to the worst point in its recorded history. Last week the Department of Health and Social Care (DHSC) and NHS England jointly released a two-year plan to fix England’s broken emergency care system. Boyle believes its aim to increase the number of patients seen in A&E within four hours to 76 per cent by March 2024 is not ambitious enough, and that 95 per cent should be the target instead.
The crux of the two-year strategy is increasing capacity in hospitals. This includes £1bn of funding for 5,000 new beds and 800 new ambulances, 100 of them specialist mental health ambulances, and securing more clinical resources for the NHS 111 urgent care phone service by encouraging retired doctors to return to work. The Guardian has reported that the £1bn pledged is not new money, and will come out of funding announced last year in the Autumn Statement. “Historically, urgent and emergency care in this country has been relatively under-invested,” says Boyle.
The plan also promises £1.6bn towards speeding up hospital discharges to social care settings, and utilising “virtual wards”. This would entail more patients being monitored at home, allowing healthcare staff to care for up to 50,000 patients remotely per month.
While the RCEM is broadly supportive of the plan, the target of 5,000 beds is short of what the college recommended last year – 13,000 new beds across the UK over the next five years. Boyle says he is sceptical about the use of virtual wards as a replacement for all hospital care: “It mustn’t be seen as a smokescreen for actual beds.”
But there are scenarios where home-based care could be positive for patients and save hospital resources, he says. Someone with a long-term respiratory condition such as chronic obstructive pulmonary disease (COPD), who knows how to manage it and could recognise when they need extra support, could contact their specialist when needed, saving them trips to hospital. Equally, home care could be used to decrease long hospital stays, which are often dragged out by administrative procedures; people could go home sooner and clinicians could “tie up loose ends” from there.
However, Boyle has concerns that increasing home care could result in unnecessary treatment and actually drain resources, such as for patients with mild Covid or flu symptoms. “One of my worries is that we could end up looking after a lot of people who didn’t need looking after,” says Boyle. “This is a problem that bedevils any new service within the NHS – build it, and they will come. It’s supply-induced demand.”
The service might also siphon specialists away from insufficiently-staffed hospital wards. “Who’s going to do the work?” Boyle asks. “There is a finite labour pool. The [worst-case scenario] is that people who didn’t need looking after are being looked after by the most senior doctors and nurses.”
Instead, he believes there needs to be more investment in social care for when people leave hospitals, and streamlining the transition from hospital to social care. “Every government has ducked this important issue and it’s got to be fixed,” he says. “It cannot be that we keep people in a more expensive level of care when they could actually be at home with a care package, or occasionally needing residential care.”
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Ambitious plans to increase the number of beds or ambulances aside, the NHS’s depleting workforce limits the effectiveness of any strategy. Official statistics from September showed that there were 133,446 vacancies in the health service, nearly 47,500 of which were in nursing and more than 9,000 for doctors. The emergency care plan mentions the need to recruit and retain more staff but lacks detail on how to do this. The government is due to publish a separate NHS workforce plan soon.
Getting people into healthcare professions is the first hurdle. Medicine is still a popular university subject, and medical school chiefs have claimed that 2022 was the hardest year “in living memory” to get into medical school due to a lack of places. Both the RCEM and its fellow professional body, the Royal College of Physicians, are calling on the government to increase the number of medical school places available per year from 9,500 to 15,000.
The second hurdle is keeping people in the sector once they are there. Boyle says the government must focus on retention. “It takes a long time to grow a doctor or a nurse,” he says. “We are anxious that we are haemorrhaging senior staff. They’re expensive but they’re also valuable. They’re the people who know how to get things done and train new people coming through.”
Pay has been a major factor in many healthcare workers leaving. Unions argue that wages have not risen in line with inflation. “We know that there is a retention crisis and staff need to feel valued,” says Boyle. “And we hope that everything can be done to end the strikes as quickly as possible.”
Increasing transparency around hospitals’ performance is also part of the government’s plan. NHS trusts will now be required to publish monthly figures on how many people are waiting longer than 12 hours after arriving at A&E. Previously, NHS trusts have only had to publish figures for four-hour waits and waits of 12 hours after a hospital’s decision to admit a patient.
Such scrutiny could place even more strain on staff, but Boyle says the new system will be more “honest” and help to pinpoint geographically where the biggest problems lie, as well as help to improve care for those who are never admitted. “It may create more pressure, but we hope that’s pressure in the right place,” he says. “Hiding a problem is a not a good way to try to sort it out.
“It will bring back scrutiny on people who are waiting a long time to be admitted, because without that, once somebody has been in the department for more than four hours they suddenly become invisible to the system.” Publishing these figures will also bring England in line with Northern Ireland and Scotland’s reporting practices.
While the government plans for NHS investment, the idea of privatisation has been mooted as a mechanism to reduce waiting times. The government recently announced that it planned to “turbocharge” the use of private hospitals to clear the backlog, while Sajid Javid, the former health secretary, recently called for patients to pay for A&E visits.
Charging patients for emergency care would only increase health inequalities, says Boyle. “I think this is a distraction,” he says. “Whenever you come up with some way to discourage people from using a service, you harm the people who need it the most. It’s an idea that’s been around for years, and there’s good reason it’s not been implemented.”
Instead the government should focus on increasing the workforce and implementing the plan it has laid out, he says. To avoid the catastrophic conditions of last year, it needs to do better than empty rhetoric. “December 2022 must never be repeated,” he says. “It was so dangerous and so appalling. I hope that is the lowest we ever get to in emergency care.”
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