Published on March 11, 2014
There are three proven ways to Stop people coming to A&E departments
Current NHS theory: Once you have arrived at an A&E department, then prolonged hospital admission is almost inevitable!
Heard it all before? Chris Moulton Department of Emergency Medicine Royal Bolton Hospital Vice-President College of Emergency Medicine
Royal Bolton Hospital
Royal Bolton Hospital
Nearly 20 years of problems in A&E Departments: 1996 to date
Last big episode of trouble was 2001: beds and trolley waits This time (2014) it is medical staffing and lots of other things!
Reasons for the problems? An ageing population suffering from more chronic illnesses (especially dementia) with relative lack of social support and community care (People over the age of 60 make up nearly a quarter of Britain’s population; half of them have at least one chronic illness) A withdrawal from round-the-clock care or arduous rotas by many health care professionals (both in hospital and in the community)
More reasons…… Reduction of the NHS hospital bed stock with inevitable consequences in the ability of the system to respond to surges (The number of acute hospital beds has decreased by a third in the last 25 years whilst bed occupancy rates have increased from around 80% in 1997 to nearly 88% in 2012) Hospital exit blocks due to cutbacks in community and social care
And more...... More complex treatments with instructions to “go to A&E” in the event of problems Increased numbers of patients with mental health and alcohol problems Immigrant populations that have no previous experience of UK general practice and may not be registered with a practice Complex systems of access to urgent care that either do not deliver what they claim to or that defy understanding by patients
And even more…… A 24-hour society (If you can shop at 2-00am, then why can’t you go to an A&E department and have an x-ray at 3-00am?) Political tampering with healthcare systems without any trials or evidence base for the costly “improvements” that have been introduced And many others………….
Consequences for EDs: Poor experiences for patients Failed targets Financial losses for providing emergency care Dysfunctional A&E departments Angry managers Unhappy doctors and nurses
The Keogh Report: Aspirational ideas; rely on many things changing to work Not much until 2015 No mention of current staffing crisis in EDs Recommends ED and UCC co-location Not costed Plans hospital reconfiguration but different from trauma Major injuries, strokes, STEMIs and AAAs already move Over 95% of patients would not benefit by transfer
Major Emergency Centres MAJOR Trauma and stroke but not PCI
Keogh Report plans: NHS 111 Paramedics Self-care GP OOH Community care NHS provision of IT Bed reservoir and increased diagnostic capacity Correct staff to patient ratio (Berwick Report) Inadequate size and poor facilities of EDs Targets and quality indicators
Educating the public………..
NHS 111 Phone before you go = 10 million extra phone calls per year! Who will answer them, will diversions be safe and how much will it all cost?
NHS 111: Phone before you go!
Care in the community by paramedics and community matrons………
So what is our College doing about it?
CEM response: 10 priorities Published in November, just before the Keogh Report On one side of A4 paper only Five things that CEM are doing Five things that we need others to do Lots of media interest
Our 10 priorities………….
CEM priority number 1: Clear provision of urgent care Provide effective alternatives to A&E for patients without acute severe illness or injury seven days per week and at least 16 hours per day A&E cannot mean 'Anything and Everything‘ anymore ; no other healthcare system works in this way
The best known brand name:
If people keep walking across the grass, then build a path…..
Co-location of EDs & UCCs
Problem! Have you seen all those expensive but empty Urgent Care Centres?
Problem! The A&E paradigm!
CEM priority number 2: Ensure that exit block does not occur Crowding has been shown to increase mortality Even for patients who are not admitted to hospital Over 12, 000 patients spent 12 hours or more on trolleys in A&E departments last year Another 250 patients waited for 24 hours and one patient for almost three days!
Problem! How do you make all those independent CCGs all do the same thing?
Hospital bed numbers per 100,000 population: The European Union average is 590. Germany has 829 . The United Kingdom average is 389 . The Royal Bolton Hospital has 253.
CEM priority number 3: Sort out the tariffs Amend the tariffs so acute trusts are not penalised by each and every non-elective admission - Perverse incentives produce dysfunctional systems Up to 40% of patients leave A&E departments with no treatment This does not equate to nothing being done or not needing the services of an ED! CEM plan: Set up sentinel sites!
Problem! Minor injuries......
CEM priority number 4: Although we are not a trade union…… Revise the current employment contracts to better recognise evening, night and weekend work as well as the intensity of A&E work Conditions of service should be equitable not identical For other specialties too…… Not more money
CEM priority number 5: Use the money carefully Ensure that money is spent wisely and strategically Last year, £120 million was spent on emergency medicine locums Over reliance on locums is a feature of fragile systems Some use of locum doctors is fine…..
CEM priority number 6: Better care Working with patients, regulators, employers and government to improve emergency care and patient experience
Problem! So nobody wants to be an emergency physician anymore!
CEM priorities numbers 7 & 8: Getting and keeping ED doctors Promoting careers in Emergency Medicine in partnership with the Health Education England task force Encouraging and advocating sustainable, flexible and rewarding careers at every level
They are leaving: 78 in 5 years! 3 2 19 13 15 21 0 5 10 15 20 25 2008 2009 2010 2011 2012 2013 Fellows (Consultants) who have moved overseas since 2008*
Their top five reasons: High work intensity Financial aspects Feeling unappreciated Lack of resources Inadequate staffing
Other reasons: Poor conditions of service Unacceptable workloads Lack of support from other hospital staff Trolley waits Inability to do their best for patients Shabby small A&E departments Constant criticism
Retention versus recruitment The consultant job The staff doctor job The trainee job Fair terms and conditions of service The ED environment and working conditions
CEM priorities numbers 9 & 10: Getting and keeping more ED doctors Establishing transferable competencies to encourage and enable more doctors to join Emergency Medicine Implementing run through training - allowing trainees to plan for six years and not just three years
Predictions are always difficult to make - especially when they concern the future
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