THERE is a huge crisis in A&E departments in English and Welsh hospitals.
Emergency patients brought to A&E departments by ambulance frequently have to wait outside for hours, waiting for A&E to accept them.
When they do get in, many have to wait more than four hours before a decision is made to admit or discharge them. And once the decision has been made that they need admission to a hospital bed, there are rising numbers who have to wait for more than 12 hours on an A&E trolley for that bed.
Hospitals are fined for ‘breaches of the four hour wait target’ in A&E. Hospital trust managements therefore have a financial incentive to tolerate queues of ambulances outside, as the clock does not start ticking for the four hour wait target until the patient is downloaded into the A&E itself.
Parts of Wales and East Anglia are particularly badly affected. At the Norfolk and Norwich University Hospital Foundation Trust over Easter Weekend there were 15 ambulances waiting outside, so that for the first time in Britain a tent was erected in the grounds to act as an annex (which in the end was not used).
Clearly the longer emergency patients wait in an ambulance, not receiving the definitive diagnosis, investigations and treatment that they would be receiving inside the hospital, the more their condition deteriorates.
In addition, even when patients do eventually get transferred onto an A&E trolley, the proportion who get sorted out (a decision made as to admission or discharge) within four hours is getting less.
The government’s target, is that this should happen for 95% of patients in A&E within four hours.
This average figure was reached in 2011/12, but was not reached in 2012/13 at 94.9%
At the start of this year 2013, only 18 of the 143 trusts which have major A&Es, have hit the 95% target. A list of the ‘worst performers’ has been drawn up which includes major university hospitals such as Leicester, North Staffs and Coventry and Warwick.
There has been a steady rise over three years in the numbers of very sick patients (Type 1) waiting over four hours. In the first four months of 2013 this was 404,654 compared to 269,821 in 2012 and 215,487 patients in 2011.
Further, once patients have been assessed and judged ready to be admitted, the numbers spending a further period waiting in A&E for more than 12 hours has risen.
In 2011/12 this number was 123 patients, whereas in 2012/13 the number was 167 patients and in the first two weeks of this year already 40 patients have waited more than 12 hours.
The inklings of this massive crisis building up in A&Es, were given vent in a major policy speech by Health Secretary Jeremy Hunt on 25th April.
He suddenly announced plans to ‘rethink the role of primary care’ and remodel it to prevent emergency admissions and A&E attendances. He said that ‘inaccessible primary care’ was the cause of the rising pressure on A&E departments and that GPs must return to looking after patients in the community and ensuring they don’t become ill, rather than seeing themselves as a ‘gateway’ to referring patients to hospital.
Hunt was looking to explain a huge rise in patient attendances at A&E which has seen an extra four million people a year using emergency services compared to 2004, reaching around 21 million in 2012. There was a one million increase in attendances at A&E last year alone.
The government and the new national commissioning board (NHS England) have had to produce an emergency statement, an A&E improvement plan and a letter to all healthcare providers demanding that A&E performance improves.
On 9th May, NHS England put a statement on its website which began ‘Plans to strengthen performance in urgent and emergency care are being put in place across the country to help hospital A&E departments.’
It pointed out that hospitals are only paid 30% of tariff for all extra patients admitted through casualty (over and above the emergencies admitted in 2008/9).
It proposes the setting up of Urgent Care boards, coordinated by NHS England, the NHS Trust Development Authority and Monitor, and that the remaining 70% of the fee should be used to make specific improvements including in A&E departments.
The sums involved are a drop in the ocean. It is reported that Hunt wanted to announce around £300m to address the A&E crisis, but that the money may not be available.
The improvement plan ‘NHS England: Improving A&E performance’ suggests that the A&E crisis is due to the following causes;
• lack of primary care and community services especially out of hours services
• the introduction of the 111 telephone number
• the lack of focus for commissioners and uncertainty about changing roles in the new system.
• the pressure on the social care budgets
• the impact of the Francis report on clinical decision making
• the reduction in bed numbers and staff as hospitals try to deliver cost improvement programmes.
This list itemises the devastation that the government has wreaked on the NHS, all be it in very under stated language.
There are not enough GPs. They are too booked up. It is very difficult to get an urgent appointment to see the GP and consultation times are limited to ten minutes.
The out-of-hours service has deteriorated drastically since 2004, when the change in GP contract enabled private companies to bid to provide these services, on contracts which allowed them to provide vastly inferior care. Patients rightly do not trust these services and get themselves to A&E in desperation to get properly seen by a doctor.
The roll out of the 111 non emergency telephone line has been an unmitigated disaster, handing out contracts to 46 different companies, and giving the job of deciding where to direct patients seeking medical advice to clerical staff. Twenty two serious incidents have already been reported and three deaths.
The ‘new system’ brought about by the Health and Social Care Act, has brought about massive top down reorganisation and chaos.
There has been a 20% cut (i.e. £2.7bn) in the social care budget in the last two years, so that sick and elderly people have far less support to care for them in their own homes.
The shocking revelations of the Francis report has encouraged nurses and doctors to stand up to bullying management and more conscientiously provide what patients need and make sure they are admitted to hospital if necessary.
But the key issues are funding, beds and staff. The A&E crisis is a hospital crisis. Because of the £20bn QIPP cuts, the so-called 5% per annum efficiency savings, hospital trusts have made thousands of staff redundant and there are simply not enough doctors to see the patients quickly in A&E, or beds to put them in.
Estimates have been made that 5,000 extra middle grade doctors are needed in A&E. There is no way the A&E crisis can be solved outside of calling a halt to the massive funding cuts and the hospital closure programme.
Professor David Oliver, the former national clinical director for older people, states that the UK has lost 30% of its acute hospital beds in the last 20 years, leaving the UK with fewer beds per head of population than any comparable advanced country.
He said patients would be left being treated on corridors and ‘on any flat surfaces available’.
Indeed the RCN representative for East Anglia told the RCN conference, that doctors had to perform ‘safari ward rounds’ searching all over the hospital for patients who had been parked in inappropriate wards and spaces just to get in.
The government’s plan however is to continue along the same course which led to the crisis. The Urgent Care boards are pressing ahead with all the government’s policies as outlined in the NHS Commissioning Board’s annual plan ‘Everyone counts: Planning for Patients 2013/14’, including the annual efficiency savings, and hospital ‘reconfigurations’.
In fact, the government’s hospital closure plans are to be stepped up. On 10th May, the government announced the details of its new Care Bill.
In addition to detailing funding for long term social care, this Bill gives new powers to the Care Quality commission.
It will be given Ofsted-type powers to publish ratings on hospitals and care services.
But worst of all it will have the power to recommend the closure of hospitals. At the present time Monitor can put a hospital into administration if it is ‘financially unsustainable.’ The CQC is to be given the power to require Monitor to put a Foundation trust into administration if it becomes ‘clinically unsustainable’.
This explains the extraordinary outburst by David Prior, the new head of CQC, (former head of the Norfolk and Norwich hospital) who told the Kings fund on 8th May, that ‘emergency admissions through A&E are out of control in large parts of the country’ and as a result the healthcare system is on the brink of collapse!
He said: ‘We will be outside the system and the politics. We will have a huge role in the reconfiguration debate as we are independent. If we don’t start closing acute beds, the system is going to fall over’.
The priority for the government is simply to close hospitals down. The CQC, armed by the new Care Bill, is planned to be the new weapon to do this.
However, there is a powerful movement of millions of workers, youth and the middle class marching, picketing and rallying, determined to defend of the NHS.
Tens of thousands at a time have turned out against planned A&E and Maternity closures in Chase Farm, Lewisham, Ealing, Charing Cross, Hammersmith, Central Middlesex, Manchester, Liverpool and Stafford already.
It is urgent that trade unions stop turning the other cheek.
Patients are already losing their lives in the Tory rush to dismantle our NHS hospitals.
The unions must take up the defence of all hospitals with occupations to stop the NHS cuts and closures and call a general strike to maintain the NHS in public ownership by bringing in a workers government and socialism.
