This winter has been like no other. The peak of the second wave coinciding with winter pressures has placed a significant burden on the Urgent and Emergency Care system. As we recover from the pandemic, the NHS faces significant challenges in tackling the elective backlog and managing the demand from easing coronavirus restrictions. We must use the summer months effectively to prepare for the challenges ahead. Our Summer to Recover campaign outlines a series of recommendations to ensure that Emergency Departments do not become the system failure service this winter.
The NHS could not cope with winter pressures before the pandemic. Every winter elective surgery was compromised. Crowding and corridor care, which were experienced all year round in many departments, became increasingly dangerous, and this became particularly visible with ambulances queuing outside Emergency Departments. The pandemic has shone a brighter light on these system failures.
Without adequate planning, Emergency Departments will be forced to sustain other parts of the health and social care service. This will result in a dangerous return to crowding and corridor care, which should never be the accepted norm of system pressures. Planning for winter must start now.
Below we outline a series of important actions to winter-proof the Urgent and Emergency Care system.
1. Embed Unscheduled Care firmly into recovery plans and allocate sufficient funding to support the whole Urgent and Emergency Care system
We do not underestimate the scale of the challenge ahead in terms of tackling the elective backlog. Emergency Departments are also impacted by this as patients may present to Emergency Departments with potential complications from delayed or cancelled procedures. There is unmet need amongst patients with serious symptoms that have delayed contacting health services until now. In addition, we would like to see a more sustainable financial settlement to Emergency Departments, so they are resourced to meet demand all year round.
2. Expand capacity and restore acute hospital beds To keep patients safe from Covid, hospitals have been reconfigured, resulting in a loss of beds. The UK has traditionally run its hospitals with relatively few beds per head and this has created exit block.
As we begin to recover from the pandemic, we are calling for transparent bed and workforce modelling with a commitment to act on the findings before winter to allow for safe restoration and expansion of bed capacity to above pre-pandemic levels.
3. Be transparent about the efficacy of the NHS 111 First and other equivalent phone-first services Iterations of a new appointment booking model for Emergency Departments have the potential to improve patient experience and reduce crowding in ambulatory areas in Emergency Departments this winter. However, these must be robustly evaluated, with the results and data published in full so we can understand patient behaviour and the impact on Emergency Department presentations. This must go hand-in-hand with an increase in alternative provisions across the UK that phone-first services can direct patients to.
4. Commit to using the 12-hour data from time of arrival for all Emergency Departments to drive plans for winter
The 12-hour data as currently published in England, is from decision to admit the patient, which is a gross misrepresentation of the true scale of crowding and long waits in Emergency Departments. The 12-hour data from time of arrival is now collected in all four nations. This data highlights the significant flow and exit problems that compromise the safe delivery of Emergency care. All four nations must act now to stop long Emergency Department stays.
1. Ensure there is adequate alternative care for patients with urgent problems who may be better cared for elsewhere Patients should only attend hospital when it is essential, or when the clinical value outweighs the risk. To support this, we would like to see progress in adopting a consistent, expanded model of Same Day Emergency Care (SDEC) and Ambulatory Emergency Care which is available twelve hours a day, seven days a week.
2. Use 12-hour data from time of arrival to proactively address crowding and corridor care It is crucial that 12-hour data from time of arrival is understood for the harm it represents and is acted upon. Trusts and Boards should use this information to actively plan to eliminate exit block. No patient should ever receive clinical care in a corridor.
3. Work actively with local health systems to ensure that service provision matches local population need. There are twice as many attendances to Emergency Departments in the most deprived areas compared to the least deprived areas, representing a failure of core health care services and prevention. Integrated Care Systems provide an opportunity to redress these inequalities by coordinating health services and improving access to primary care, alternatives to admission, and providing community-based services.
1. Ensure robust Infection Prevention and Control measures are in place in Emergency Departments.
It is vital that the highest standards of Infection Prevention and Control measures remain in in line with RCEM’s Infection Prevention and Control Best Practice Guidelines.
2. Encourage the vaccination of all staff working in Emergency Departments.
We are eager to ensure that all our workforce – from doctors and nurses to support and security staff, cleaners, and porters – have equity of access and information regarding the coronavirus vaccine. We encourage Emergency Department Clinical Leads to engage proactively and support colleagues who may be worried or vaccine hesitant. For winter 2021, Flu vaccination must also be a priority.
3. Support and promote the wellbeing of staff working in Emergency Departments.
After a difficult year, it is important for us to focus on staff retention and sustainable careers for all. There are a number of actions Emergency Department Clinical Leads can take to support staff including: encourage staff to take their annual leave, ensure rotas reflect intensity of work and allow for adequate time off between shifts, protect training time for learners, and protect teaching time for faculty.
4. Escalate any ambulance handover delays due to capacity to senior Trust and Board management.
Ambulance handover delays are a visual representation of crowding in Emergency Departments; they are caused by poor patient flow in hospitals. Delaying ambulance handovers should be a last resort. RCEM and the College of Paramedics have published an options appraisal to support good decision making for ambulance handover delays.
For more information, please contact policy@rcem.ac.uk
