Pressure on emergency departments

Pressure on A&E – or emergency departments - across England has been in the news throughout the holiday period. Dr Ali Sanders, chief of service for emergency medicine at Imperial College Healthcare gives her view of the situation. The Trust provides both A&Es and urgent care centres at Charing Cross and St Mary's hospitals as well as a stand-alone urgent care centre at Hammersmith Hospital. St Mary's also has one of four major trauma centres in London. The Western Eye Hospital provides a specialist A&E eye service.

Like many NHS Trusts, we have been struggling for some time to meet the national standard for 95 per cent of people attending emergency departments to be assessed, treated and admitted, or discharged within four hours. So, what's going on and, more importantly, what do we need to do to improve our service?

First of all, I just want to make the distinction between a safe service and a speedy service. Of course, there are connections between the two and, as a general rule, the four-hour performance target is good for patient care as it drives the whole healthcare system to look at improving emergency pathways. It is essential that we identify those with the most serious conditions and make decisions about their care straight away. It is also important we see patients in the right place. In order to do this we stream patients according to need as soon as they arrive into our emergency care pathway through a number of entry points – for example, patients with a minor illness or injury will be cared for in an urgent care centre while someone with a suspected heart attack or stroke will go straight to a resuscitation area. During the past year, we've increased the number of emergency medicine consultants we have as well as the availability of other consultants to make decisions about specialist treatment when required. More recently, we have also introduced an 'escalation' policy that sets out how our whole Trust should provide additional support at times of very high pressure on the emergency departments.

Back to what's causing our current challenges: I think we, in emergency medicine, are on the sharp end of issues arising all the way through the health and social care system, including:

• Patients attending our emergency departments over the past year are, in general, more poorly than those who attended in the previous year.
• More ambulance patients are attending our emergency departments, particularly at Charing Cross. Many need admission to an inpatient ward which is affecting our total capacity across the Trust.
• There are real delays in transferring patients who have completed their treatment with us into community-based care or - if they have been admitted for very specialist care - to their local general hospital. This means patients sometimes have to wait longer in the emergency department before a bed is available for them to be admitted to an inpatient ward. Most days, we have the equivalent of around two wards of patients who should have been able to move on to more appropriate care. The effect of this backlog on the emergency departments can lead to significant overcrowding.

Given this complexity, we are working with partners in the wider health and social care system to make improvements as well as improving our own capacity and systems. In the short term, this includes:

• Opening additional beds, just before Christmas, at St Mary's and Charing Cross hospitals - though we are now at the limit of the physical space available in our current facilities.
• Expanding our 'ambulatory' urgent and emergency care services so that we can run tests and treat more people as 'day-patients', avoiding overnight stays in many cases.
• Making it easier to transfer patients back to their local general hospital or to local community services when they are ready.
• Making our own discharge processes as effective and efficient as possible, including having a dedicated discharge team on hand to support wards seven days a week.

These measures are already having an impact as we've seen performance against the four-hour standard improve over the past week or two but we still have some way to go.

The answer longer-term lies in new models of care. In particular, we need to be doing much more as a health service to enable people to get the support they need at home or in the community to stay as healthy as possible. And, as importantly, we need to make sure that when people do need a spell in hospital, it is arranged promptly and is for very focused assessment and treatment. A busy, acute hospital simply isn't the best place to be for any length of time, especially if you are frail and elderly, as an increasing proportion of our emergency patients are. Even if it were possible, continuously expanding emergency department capacity isn't going to meet the changing health needs of our local communities.

I hope this blog post goes some way to explaining why so many emergency departments are under significant pressure currently, and how we at Imperial College Healthcare are responding. You can help by making sure you know where and how to get the right care to meet your health needs, whether that's in one of our A&E departments or at your GP practice or local pharmacy - read more about where to go for care. But please be assured, despite the challenges, all our emergency services continue to provide great care and to save lives every single day of the year.

We publish our A&E performance data weekly on our website. For details on our A&E services see our service directory. 

Find out more about the pressures on emergency services in this King's Fund animation - an alternative guide to the urgent and emergency care system in England. 


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