Emergency departments across the country have just endured one of the toughest winter periods on record. Waiting time breaches reached record highs, emergency admissions soared and thousands of patients faced long waits on trolleys. While patients should always be treated on the basis of need rather than arbitrary waiting time targets, there can be no doubt that rising demand on services coupled with the seasonal spike in demand left patients facing unacceptable delays in treatment this winter.
For many hospitals, the pressure on emergency departments was simply too great. With services stretched to breaking point and doctors and nurses unable to move patients through to appropriate wards, many hospitals were put on “black alert”. A recent survey of doctors found that a staggering 29% of respondents reported a black alert being implemented at their place of work, up 22 percentage points on the same quarter last year. When this happens all but essential care is postponed, staff may be called in for extra shifts, and ambulances and patients can even be redirected to other hospitals. Demand doesn’t disappear, it is simply shifted elsewhere.
The effect on patients is considerable. It can often mean that patients have operations cancelled moments before they are due to be taken into theatre, causing tremendous stress, anxiety and inconvenience for people who have waited weeks or months for treatment.
It’s important to remember that while there may not be weekly performance figures for other parts of the system, what’s happening in emergency departments is reflective of, and linked to, wider pressures across the NHS and social care sector. You can’t address problems in emergency departments without looking at the system as a whole.
Problems at the hospital front door are often linked to delays at the back door. A shortage of social care beds creates “exit block”, meaning patients can’t be discharged because there is simply nowhere for them to go. This, coupled with a shortage of hospitals beds, leads to patients waiting for hours on trolleys or being admitted to a ward that is not appropriate for their needs, affecting the quality of care they receive.
Rather than coming up with a long-term plan to deal with what has become an annual A&E crisis, for years politicians across the spectrum have opted for what can best be described as sticking plaster solutions, designed to respond to headlines, rather than actually equip the health and social care services with the staff and resources they need to meet rising demand. The result is that we aim to manage, rather than prevent, a winter crisis, but we have failed to achieve even this in recent years.
Increasingly, money for emergency services – usually taken from elsewhere in the NHS budget – is announced in the weeks and months running up to winter to help hospitals cope. But this is almost always too little too late, and ignores the fundamental problems. Demand is growing with an expanding and ageing population, but resources are being stripped out of frontline health services at an average of 4.8% per year – the “cost improvement programme”. A majority of hospitals are no longer able to cope and are forecasting financial deficit. Recycled money pushed around the system makes no difference. What makes it even worse is the failure to sort out social care, with governments seeing it as a local authority problem, but patients knowing that their continuing care depends on good services.
There are no fast and easy answers. The causes are complex and so are the solutions. Above all, we need to look at the system as a whole and urgently address chronic underfunding of services, which is set to reach £30bn by 2020. Investment needs to keep up with demand. Every part of the system – from our GP surgeries, to hospitals, to community care – needs to be supported, joined up and working well, and we must address acute staffing shortages in areas such as emergency medicine and general practice. We must also address an out-of-hours telephone service, NHS 111, which is still falling short because it is not clinician-led, leading to some patients being sent to A&E unnecessarily.
In the meantime it would really help to lift spirits and restore morale if the government would admit that too much has been expected of staff, and commit to supporting them and improving working conditions.
The NHS is recognised as the best healthcare system in the world, and the most efficient. But it has now reached a crossroads. Staff have done as much as they can to protect and improve patient care but after years of underfunding, and with plans to make more cuts through the next parliament, the cracks are beginning to show. That’s why the BMA is calling for an end to political game playing with the NHS and for a far-sighted funding and purpose plan for the health service.
We’re calling on all politicians to put patients first and commit to a long-term, system-wide plan to find real solutions to these problems ahead of winter 2015 and beyond. More broadly, we’re calling for a review of the country’s health and social care needs and the funding required to meet them. There are no easy answers, but without this long-term approach our ability to meet rising demand and protect a health service true to its founding principles will be under threat. It’s not too late to turn things around, but if we don’t end short-term political game playing, it soon will be.
