The current pressures on the Welsh NHS laid bare as Covid hospital admissions rise
The past 18 months have been relentless for staff working in the Welsh NHS.
The first wave of the pandemic brought great uncertainty to the workforce who, in many cases, were drafted into unfamiliar roles to treat Covid-positive patients on the front line.
The second wave was arguably even more devastating with the highly-infectious Delta variant causing an even higher volume of infections, hospital admissions and, sadly, deaths.
We're now into the (possible) peak of the third wave which, thanks to vaccinations, has led to a greatly-reduced number of people becoming seriously unwell and needing hospital care.
But in recent weeks, as community infection rates have soared to levels not seen for nine months, doctors and nurses have become increasingly concerned at the prospect of tackling Covid alongside routine appointments and procedures.
Here we look at the current state of the Welsh NHS including both the acute end of the system, such as the Welsh Ambulance Service and A&E, and those in primary care such as GP surgeries.
The Welsh Ambulance Service
Lee Brooks, director of operations for the Welsh Ambulance Service, admitted that August's easing of Covid-19 restrictions had led to demand for ambulance services rocketing to the highest levels seen since April.
"In recent times we have seen approaching 13,000 emergency calls connect to us per week. As an illustration this is an increase of approximately 3,000 per week or over 400 a day when compared to previous years," he explained.
"Our most common complaint is breathing difficulties and as the seasons change this can aggravate conditions such as asthma.
"We are continuing to monitor trends in our demand and it is now fair to say there are early signs that Covid impacts could be contributing to our demand."
The Welsh Government-set target is for 65% of the most life-threatening calls to the ambulance service, known as 'red' calls, to be reached within eight minutes. However, while this was met for each month between April and July 2020, it soon took a nosedive and has not been reached for the past 12 months.
In July 2021 just 57.8% of emergency responses to red calls arrived within eight minutes.
Lee said one of the biggest issues facing the Welsh Ambulance Service was handover delays when ambulances are unable to offload their patients into busy A&E departments.
"Hospital handover delays have also peaked and last week over 3,700 ambulance hours were lost across Wales outside hospitals," he said.
"We recognise however that this is a system-wide issue and we continue to work with partners across the board to improve flow, including from hospital to social care, especially as we approach the winter period."
Due in part to the very nature of the job sickness absence rates among Welsh Ambulance Service staff are often higher than any other health board or trust in Wales.
"It has been a very difficult 18 months and our staff have felt the impact of what has happened," Lee admitted.
"We are experiencing high staff absence due to sick or following Covid isolation guidelines. Approximately a quarter of these absences have been stress-related.
"We wish to thank all of our amazing people who continue to do their best in what are very challenging circumstances."
Hospital A&E departments
During the first wave in particular the number of people being taken to A&E departments in Wales took a considerable dip as lockdowns forced families to remain in their own homes and only venture out for essential reasons.
However as restrictions have eased attendances to emergency units have increased every month since February 2021 – and in June 2021 surpassed pre-pandemic levels.
The latest data shows that there were just over 94,000 attendances to all NHS Wales emergency departments in July 2021, which is 28% higher than in the same month last year.
Somewhat inevitably this has had an impact on waiting times with some patients spending truly astonishing amounts of time in A&E before being admitted, transferred, or discharged.
Earlier this month we told the story of Martin Nicholas, 63, from Mountain Ash who was in Prince Charles Hospital's emergency unit for in excess of 40 hours.
The Welsh Government target is for 95% of patients to be in A&E no longer than four hours before being admitted, transferred, or discharged while no patient should wait more than 12 hours.
However, in some hospitals barely half of patients where there for four hours or less according to the latest statistics for July 2021. Ysbyty Glan Clwyd in Denbighshire recorded the worst figures of any Welsh hospital in July with 44.7% being admitted, transferred, or discharged within four hours.
Wales-wide an astonishing 7,084 patients (7.5%) were in A&E for 12 hours or more in July – one of the highest such figures on record.
Dr Suresh Pillai, vice-president of the Royal College of Emergency Medicine Wales, said staff in A&E are in a continuous battle to try and keep patients safe.
"Currently we are facing severe pressures in the emergency care system in Wales. We are seeing winter pressures in the summer. Demand has been extremely high and staff have been struggling to manage demand effectively," he said.
"Our priority is keeping patients safe. Healthcare workers are doing all they can to maximise infection prevention control measures and to maintain flow through the hospital. But the sheer volume of patients is affecting our ability to do this and has been resulting in an unacceptable return of crowding in our emergency departments."
He said the workforce entered the pandemic short of staff and short of beds and after 18 months of "relentless work" the existing workforce is "burned out".
"It is incredibly difficult for staff to do their jobs effectively and deliver high-quality care. But it is also difficult for patients who may be facing longer waits than usual," he said.
"We understand the frustration that patients may feel but healthcare workers are working harder than ever to deliver effective care quickly and ensure that patients do not have to wait too long."
He called on health boards and the Welsh Government to take "swift, effective action" now – including expanding capacity to ensure there is enough space to manage the current numbers of patients.
"They can also work to maximise the efficacy and quality of same-day emergency care and discharge to assess while simultaneously ensuring that local services including social care services are resourced sufficiently to support patients coming to and from hospital," he said.
"It is an extremely challenging time and we are increasingly concerned about the upcoming winter. These are system-wide problems of resourcing, capacity, and workforce shortages that urgently need comprehensive solutions and a joined-up strategy from the government. Without a plan the health service may well be heading into a crisis this winter."
Covid patients in Welsh hospitals
As of September 13 there were 591 people in general and acute hospital beds with coronavirus – that includes those who are confirmed or suspected of having and also recovering from Covid-19.
That number has been increasing for several weeks and has almost doubled when compared to a fortnight ago (330 on August 30).
Thankfully these are nowhere near the levels seen in the first and second waves. In comparison on January 13 this year there were 2,661 Covid patients on general and acute wards.
What makes the situation more perilous now is the fact there is far more non-Covid activity in Welsh hospitals which is resulting in fewer vacant beds. On January 13 there were 1,438 vacant beds but on September 13 there were only 1,118.
When it comes to coronavirus patients needing invasive-ventilated beds in critical care – the highest form of treatment – as of September 13 there were 48 people in these beds. This figure has not risen anywhere near as sharply as general hospital admissions for Covid, further indicating that people are not becoming as unwell this time around.
However death rates are rising despite the numbers of people double vaccinated. There are now roughly 40 Covid deaths reported every week by Public Health Wales. Only a fortnight ago that figure was at around 14.
First Minister Mark Drakeford has said that modelling suggests there could be 100 new Covid-19 hospital admissions every day as the Delta wave peaks in Wales.
Contrary to some people's beliefs GP surgeries have been continuing to operate throughout the pandemic in the vast majority of cases.
But they have had to adapt the way they work. They have held virtual appointments and played a huge part in the vaccination effort since the very start of the year.
But as with many areas of the NHS there is a workforce crisis facing general practice and this was the case way before the pandemic began. One of the biggest knock-on effects of this shortage has been on the length of time people have waited to access their local doctor with results from the National Survey for Wales indicating that 40% of people have found it difficult to make a convenient GP appointment.
"This shortfall in the workforce continues while the workload has markedly increased," said a spokesman for the Royal College of GPs (RCGP) in Wales.
"GPs have been working throughout the pandemic. In December, prior to the rollout of the vaccination programme, an RCGP Cymru Wales study found that GPs were on average working at 127% of capacity.
"Pleased as we have been to play our role in tackling Covid-19 and as part of a world-leading vaccination programme, without considerable sustained investment in recruiting, training, and retaining GPs there will always be workload challenges.
"Regrettably but understandably this is taking a toll on the wellbeing of GPs and their teams. If we do not care for the carers we will be resigning ourselves to losing good people from the profession and as a result an even greater pressure will fall on those who remain.
"General practice has evolved to maintain high standards of patient care during the pandemic. Going forward this increases the ways in which patients can access general practice and can reach the most appropriate member of the practice team in a timely manner for their requirements.
"However innovation alone cannot be an alternative to a sustainable number of GPs working from fit-for-purpose surgeries to best serve the patients of Wales."
The state of the Welsh NHS as a whole
Dr David Bailey, chairman of the British Medical Association in Wales, said a number of factors are contributing to the current and well-reported pressures on the whole of the NHS.
"These include rises in Covid infection rates, staff shortages, existing infrastructural challenges, limited provision of social care, ambulance availability, supply chain issues, and inadequate personal protection equipment to name a few," he said.
"The inevitable rise in Covid cases and a small minority of vaccine hesitance in some patient cohorts has undoubtedly put additional pressure on health boards with some pausing planned procedures due to bed and staff shortages.
"Despite changes to the isolation rules some doubly-vaccinated healthcare workers are still having to isolate due to treating vulnerable patients and not having sufficient equipment such as higher-grade respiratory masks to stop the spread of the virus.
"We've also very recently raised our concerns around the provision of patient transfer services and the knock-on impact on patient safety.
"Lastly the current and well-reported UK-wide supply chain issues have added additional pressures to both primary and secondary care including a low supply of blood vials which has meant cutting back on some important tests as well as a delay in the delivery of flu vaccines. The latter is expected to add considerable amount of pressure to the workload of general practices who are already experiencing record high levels of demand.
"We're working with NHS employers and policy makers to address these issues as a matter of urgency as well as continuing to improve the working conditions of doctors. This includes vastly improving occupational health services to support them with the lasting effects of the pandemic such as mental health issues, burnout, and long Covid.
"We need to do all we can to protect this vital workforce if we're to try to deliver the biggest recovery in the history of the NHS."
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