The combination of rising patient demand and tightening resources has put intense pressure on emergency care, and as winter approaches there will be further strain on already overstretched services.
The recent report from the National Audit Office points out that the number of hospital emergency admissions is rising, and it suggests that the key challenge is to reduce avoidable admissions and ensure that as many patients as possible are treated in the appropriate setting. With better NHS and social care in the community, at least a fifth of cases admitted as emergencies could be managed outside the hospital. So the key lies in reducing the number of patients who go through the open doors of the local A&E departments. The ‘open all hours’ aspect gives a comforting feel to the public at a time of distress but it makes the individual less responsible for finding, or indeed in some cases, waiting for an alternative route to seeking treatment. To tackle this, the government must develop long-term and short-term strategies to address the staff shortages across the NHS, and invest in systems and measures that direct patients to the service or setting that is right for them. The NHS reforms have categorically failed to address this issue, and indeed might have indirectly contributed to the rising tide of emergency admissions by reducing resources within the NHS.
In particular, the failure to implement policies that promote the integration of health and social care is lamentable, and an opportunity lost. If we are to tackle the increasing demands of an ageing population, we need a considered, holistic solution that is backed by an unambiguous, integrated plan produced in consultation with patients, the NHS and local authorities. The key is to ensure that there is properly resourced community care, both to provide better and more care to ailing patients in their own residences and also to facilitate early discharge from burdened hospitals. Attributing this major failure of policy to the NHS staff ignores the basic reasons that explain why the system is so strained. The NAO and the Department of Health (DH) must be aware that a 24/7 consultant service will greatly improve the quality of care and safety of patients, but it will do little to enhance the community structures required to reduce the burden of demand. The figures for four-hour waits are a significant clue to the real problem A&E staff face. Almost 25% of emergency patients are admitted in the 10 minutes before breaching the target, indicating a failure in accessing acute beds as well as community support for patients to enable their discharge from A&Es.
We are facing an unprecedented winter crisis in the NHS; official data shows a 43% rise in the numbers waiting more than four hours in A&E departments compared with two years ago. Cliff Mann, president of theCollege of Emergency Medicine (CEM), which represents A&E doctors, says: “It’s not chaos in emergency departments, but it is a crisis.”
We are in the middle of the third year of huge cuts in acute hospitals’ budgets. The British Medical Association (BMA), would like at least to halt the fall in NHS bed numbers and has urged the DH to rethink its £30bn “efficiency drive” in the NHS. We have all the symptoms of a system under pressure; these new figures are clear evidence of this. While these persist, it would be foolish to pursue a policy of constraining resources in the acute sector.
With the emerging powers of the clinical commissioning groups (CCGs) there is a distinct possibility that local resolutions will emerge. However, with the increasing fragmentation of the NHS it is clear that these solutions will come piecemeal depending on the priorities of the CCG to tackle the issue, and the co-operation of foundation trusts in realigning their own resources to beef up the community. So while the NAO offers practical advice on how to reduce emergency admissions, the implementation of these relies on the combined wills of leaders of the health and social care professions to put firm policies and procedures in place. There is, at present, no sign of this being done.
Dr JS Bamrah is interim medical director at Manchester mental health & social care trust
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Article courtesy of the Guardian