We need to be honest about our challenges this winter, plan ahead and work together
Dr Alison Sanders, clinical director of urgent care and emergency medicine, on preparing for possibly our toughest winter yet.
I often hear the rise in A&E attendances explained away as inappropriate use by people with minor illnesses or injures. But no one could say our A&Es are full of people who don’t need to be there: on the contrary, we’re seeing sicker patients as well as more patients.
Over the past two years, our A&E departments and urgent care centres have seen a six per cent increase in attendances. But over the same period, there has been a 40 per cent leap in the number of ‘blue light’ patients – those who come to us by ambulance.
At St Mary’s, one of London’s four major trauma centres, we saw a 14.5 per cent increase in major trauma patients between 2015/16 and 2016/17, greater than the 5.3 per cent increase across major trauma centres nationally. The biggest increase was among patients who were the sickest (an injury severity score of more than 15).
This rising demand and need – together with the very real likelihood of high levels of flu this year plus some wards in our older buildings out of action for urgent repairs – means our planning for winter has had to be especially rigorous this year.
The importance of good ‘flow’
We aim to assess, treat and discharge or admit at least 95 per cent of A&E patients within four hours. But, like other NHS trusts up and down the country, we are currently falling short of this target. This has been acknowledged by NHS regulators and the minimum acceptable standard has been lowered to 90 per cent up until March 2018. Our performance against the four hour standard in October was 86.6 per cent.
In reality, performance against the four-hour standard is a reflection of patient ‘flow’ across the whole urgent and emergency care pathway, not just A&E. Good flow means patients being seen by the right specialists, being admitted to the right ward, being discharged appropriately and safely – all as quickly as possible.
When the pathway flow is poor, the four-hour target becomes much more difficult to reach. When there are no beds free on the wards, it can mean keeping patients in A&E until a bed becomes available. Sometimes we breach the four-hour target because we have a patient who desperately needs a bed in a mental health unit and there aren’t any available. These scenarios are both common and extremely challenging.
Spending a long time in A&E is a bad experience for patients and it can make their recovery harder. It’s also incredibly demotivating for staff who want to provide great care for all our patients.
Improving flow
We have had a big programme underway for the past year or so to improve flow along the whole urgent and emergency pathway. This includes:
- Extending ambulatory emergency care services to evenings and weekends – providing urgent specialist review, diagnostics and treatment for suitable patients without the need for A&E attendance or inpatient admission.
- Expanding and refurbishing St Mary's A&E with £3.2 million from Imperial Health Charity – increasing the number of resuscitation bays from four to six and adding a new four-bed assessment unit within the children's A&E department.
- Increasing medical and nurse staffing in A&E – including eight additional consultants appointed since 2015 and employing our own specialist mental health nursing teams to enable one-to-one support.
- Securing direct access to 'interim' beds in local care and nursing homes – enabling safe and prompt hospital discharge for older patients who no longer need to be in hospital but who do need on-going rehabilitation or longer term care packages to be in place, at home or in a nursing home.
These improvements are making a difference. Yet, before we reach winter proper, we are already triggering our ‘full capacity protocol’ – a set of special actions we take to create more capacity temporarily in response to very high levels of demand – many times a week.
Winter planning together
We are taking additional action specifically to help through the winter months. We’re investing over £1 million on measures including 20 ‘flex’ beds that can be opened quickly at times of high demand, bringing into use up to 42 additional ‘permanent’ winter beds, expanding our hospital frailty teams with additional dedicated pharmacy and occupational therapy input, and adding additional transport and porter resource.
Working in partnership with our local communities, patients, local GPs and other health and care partners will be vital too. There are often numerous staff and organisations involved in an individual’s pathway. In a complex organisation like ours, it can be hard to ensure everyone has the information they need, easily to hand. With this in mind, we’ve developed a series of checklists and factsheets – tailored to staff, GPs and the public – to support high quality care and good flow. All the factsheets and checklists are on our website and staff intranet, and we’ve distributed hard copy versions throughout our hospitals and sent them to local GPs.
Our ‘get winter ready’ checklist for the public includes simple actions to ensure you are prepared – from how to stay healthy to how to respond if you do become poorly. It’s really important to know where to go for care and to look after friends and family who may be more prone to illness, especially those who are frail and elderly.
Even with all our improvements and planning, we need to acknowledge that this winter is still likely to be difficult. There are no simple solutions. But if we go into winter with a clear view of our challenges and the actions we can take to mitigate them, we’ll give ourselves the best chance of providing the kind of high quality care we want to offer all our patients, all of the time.
Visit our Help us get winter ready page to learn more about how we’re preparing for winter.
Download our checklists and factsheets at left.
