WP
15
Ymchwiliad
i barodrwydd ar gyfer y gaeaf 2016
Inquiry
into winter preparedness 2016/17
Ymateb
gan: Coleg Brenhinol Meddygaeth Frys
Response
from: Royal College of Emergency Medicine
Welsh Assembly Health Social Care and Sport Committee
Inquiry into Winter Preparedness 2016/17
12 September 2016
Written evidence submitted on behalf of the RCEM Wales
RCEM Wales is the single authoritative body for Emergency Medicine
in the Wales. RCEM Wales works to ensure high quality care by
setting and monitoring standards of care, and providing expert
guidance and advice on policy to relevant bodies on matters
relating to Emergency Medicine.
Question: Is the Welsh NHS equipped to deal with the pressures of
unscheduled care services during the coming winter?
- The
NHS in Wales faces a significant challenge to meet the health needs
of an aging population with increasingly complex needs. The number
of people over 65 years of age is predicted to grow by 292,000 by
2039. This is an increase of 44%.
Moreover, compared to 2011 there are already an additional 86,634
people aged over 65 alive today.
- While
these changes are significant when considered on their own, they
are compounded that elderly populations changing attitude to their
own health. Analysis of both Disability Free Life
Expectancy
and Healthy Life Expectancy
data released by the Office for National Statistics has shown that
while life expectancies are increasing those same people’s
assessments of their remaining life expectancy in good health are
decreasing.
- This
in turn is reflected in an increasing propensity to access health
services. As the King’s Fund has recently shown, demand from
this age group has grown and continues to grow considerably beyond
mere demographic change, and has resulted in rising numbers of GP
appointments both in person and over the phone.
-
As the
Danish physicist Neils Bohr once remarked, it is difficult to make
predictions especially about the future. As since
2010 the picture in Welsh Emergency Medicine has not been entirely
negative. The percentage of patients spending less than the 4 hour
target time in major A&Es reached a peak in 2013 of 87.7%
although since then performance has been in decline.
-
Moreover
the data that has so far been published by the NHS Wales
Informatics Service indicates that this decline has continued into
2016/17.
Four hour performance has so far been worse in each month of
2016/17 compared with the same period in the previous year while
attendances have risen by 1.6%.
-
The
data for patients waiting more than 12 hours is equally
concerning.
Since 2013-14 the number of patients subject to these delays in
major A&E centres has grown from 10,928 to 27,357 in 2015-16.
This is an increase of 150.33%.
-
So in
order to answer this question we need to ask whether there has been
any material changes in the facts on the ground for the NHS in
Wales since 2013 which would suggest that the situation was about
to improve, rather than continue to deteriorate.
NHS Funding
-
The
figures given below are from Stats Wales and detail NHS expenditure
per head.
Category
|
2009-10
|
2010-11
|
2011-12
|
2012-13
|
2013-14
|
2014-15
|
Total NHS Funding (£)
|
1721.31
|
1755.77
|
1759.10
|
1765.57
|
1803.82
|
1876.47
|
Social care needs (£)
|
15.78
|
14.45
|
13.99
|
14.69
|
15.93
|
16.18
|
- Although
these numbers are not adjusted for inflation, there are part of
this picture that are quite positive. Social care funding has
increased by 9.2% since 2013 – something which cannot be said
in England – and overall NHS funding has increased by 5.9% or
just under 2% per year. This again compares favourably with the
situation in England where the rate of increase has been around
0.7% since 2010.
- However,
considered more closely a different picture emerges. The Nuffield
Trust after adjusting for the fact that older populations have
higher health needs and associated costs, Wales is now the lowest
spending UK nation on its Health Service.
Moreover, since its foundation in 1948 the NHS has spending
increases of around 3.7% per annum in real terms.
This suggests that while recent spending increases are welcome,
increases of around 2% before accounting for inflation are unlikely
to arrest declines in performance.
A&E Staffing
-
The
figures given below are from Stats Wales and give details about
changes to the emergency medicine workforce since 2010.
Staff Category
|
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
% Change since 2010
|
% Change since 2013
|
|
260.19
|
274.29
|
263.42
|
287.28
|
286.03
|
288.08
|
9.68
|
0.28
|
Consultant
|
49.00
|
53.50
|
54.60
|
61.20
|
66.80
|
63.20
|
22.47
|
3.16
|
Specialty Doctor
|
28.30
|
36.45
|
43.20
|
39.30
|
45.60
|
47.85
|
40.86
|
17.87
|
Staff Grade
|
3.10
|
2.10
|
1.00
|
1.00
|
1.00
|
1.00
|
-210.00
|
0.00
|
Associate Specialist
|
20.72
|
17.52
|
17.50
|
15.86
|
12.50
|
11.50
|
-80.18
|
-37.94
|
Specialist Registrar
|
76.20
|
86.60
|
67.00
|
85.80
|
73.01
|
93.71
|
18.68
|
8.44
|
Senior House Officer
|
10.00
|
13.00
|
13.00
|
19.00
|
16.00
|
5.00
|
-100.00
|
-280.00
|
Foundation House Officer 2
|
55.00
|
51.00
|
51.00
|
52.00
|
58.00
|
50.00
|
-10.00
|
-4.00
|
Foundation House Officer 1
|
14.00
|
12.00
|
15.00
|
12.00
|
12.00
|
14.00
|
0.00
|
14.29
|
Year
|
Total attendances
|
Percentage of patients who spend less than the target time in
A&E
|
Number of Consultants
|
Consultant Per Attendance
|
2010-11
|
769897
|
85.76
|
53.50
|
14390.60
|
2011-12
|
788378
|
87.01
|
54.60
|
14439.16
|
2012-13
|
786620
|
85.46
|
61.20
|
12853.27
|
2013-14
|
773211
|
87.67
|
66.80
|
11575.01
|
2014-15
|
772954
|
81.98
|
63.20
|
12230.28
|
- Questions
of staffing are complex, but the point to notice is that although
there were considerable increases in the A&E workforce between
2010 and 2013 – when as we have seen A&E actually
improved – since 2013 that progress has stalled.
- Moreover
from 2013-14 the number of consultants per attendance has
deteriorated. This has gone from one to every 11,575 attendance in
2013-14 to one to every 12,230 in 2014-15. This echoes our wider
concerns about on-going difficulty recruiting staff to support the
speciality in Wales. These difficulties are aggravated by the
placement of major trauma centres throughout the principality and
the continued attractions of more lucrative work in other countries
such as Australia.
- Between
2013 and 2015 the workforce expanded by no more than 0.28%. One
could argue that this is a reflection of the fact that from 2013 to
2015 attendances at major A&E’s were broadly stable.
However – as we shall see further below – this does not
account the increasingly elderly profile of the Welsh population.
This means that the casemix in Welsh A&E is becoming more
complex, and more demanding, and requires a workforce of sufficient
size and with the necessary number of senior decision makers to
treat them effectively.
- Unfortunately,
more current workforce data is not yet available centrally.
However, between 2014-15 and 2015-16 attendances at major A&Es
in Wales increased by 11,125 or 1.41%.
Furthermore, the data so far published for 2016/17 shows that up to
this point attendances have been higher than last year.
Either for financial reasons or otherwise, if decisions about the
recruitment and retention of A&E do not accurately reflect the
nature of demand then performance cannot reasonably be expected to
improve.
Bed Availability and
Occupancy
-
The
figures given below are from Stats Wales and show bed availability
and bed occupancy in the Welsh NHS.
Year
|
Average daily available beds
|
Average daily occupied beds
|
Percentage occupancy
|
2010-11
|
12149.33
|
10294.16
|
84.73
|
2011-12
|
11809.69
|
10062.42
|
85.21
|
2012-13
|
11497.02
|
9923.24
|
86.31
|
2013-14
|
11241.49
|
9653.17
|
85.87
|
2014-15
|
11061.52
|
9588.74
|
86.69
|
- What
these figures show is that there has been a 9.83% decrease in bed
availability since 2010 and a 3.93% decrease since 2013. The number
of daily occupied beds has decreased by slightly less, at 7.38% and
3.49% respectively.
- While
this does something to indicate that the available bed stock is
being used more efficiently, gains has nonetheless failed to
prevent an increase in bed occupancy to levels greater than
2013.
- As
was the case for staffing data, more contemporaneous bed
availability data is not yet available. Although it is not possible
to be certain, it seems highly likely that the number of available
beds has continued to decline into 2016/17 and that bed occupancy
rates have continued to increase. This is because this would
represent the continuation of a trend seen in Wales and the wider
UK NHS for at least the last 20 years.
- This
being the case, we have evidence to suggest that there are higher
levels of demand, whilst staffing levels that have stagnated, and
there continuing declines in hospital bed capacity. Or to put it in
more simple terms, the system has more patients to deal with and
less facility with which to do so in a timely fashion. In these
circumstances it is unrealistic to expect that the percentage of
patients is going to get better.
Aging Population and Delayed Transfers
-
The figures given below are from Stats Wales collated from the
Office of National Statistics.
Year
|
Population
|
Mid 2013 All ages
|
3082412
|
Mid 2013 Aged 65 and over
|
600630
|
Mid 2014 All ages
|
3092036
|
Mid 2014 Aged 65 and over
|
614747
|
Mid 2015 All ages
|
3099086
|
Mid 2015 Aged 65 and over
|
624773
|
- What
these figures show is that the population of Wales – which
already had considerable needs centred around an aging population
– has continued to become more elderly. From mid 2013 to mid
2015 the population of those over 65 year of age increased by
3.86%. In the same time period, the populations as a whole
increased by no more than 0.54%.
- It
is
within this context that the Royal College of Emergency Medicine
takes the view that ED have struggle in the face of rising demand,
not because success is impossible, but because we continue to
systematically under-resource emergency departments in the forlorn
hope that the next redirection strategy will succeed where all
others have demonstrably failed.
- Instead
A&E should be resourced to practice an advanced model of care
where the focus is on safe and effective assessment, treatment and
onward care. While it is essential to manage demand on A&Es,
this should not detract from building capacity to deal with the
demand faced, rather than the demand that is hoped-for.
- If
this rate of growth has continued, then by mid 2016 we can expect there to
have been 632,821. This would represent an increase of 32,190 since
2013. If these figures are reflected in the age and volumes of
patients seen in Welsh A&E departments, then the casemix and
time and resources necessary to change them can be expected to have
increased. Since – as we have seen – the resources
necessary to do so have not been supplied then the situation can be
expected to become more adverse.
- One
aspect of an aging population is that more of those patients who
enter hospital are more likely to need some kind of care package in
place before they can leave. When this cannot be supplied in a
timely fashion then those patients are subject to Delayed Transfers
of Care.
- The
chart given below shows the numbers of patients subject to Delayed
Transfers of Care in Welsh hospitals since 2013.
- What
this shows is from at least 2014 the trend is clearly upwards and
the existing data for 2016 suggests that this will continue. For
example the mean average number of patients delayed per month in
2015 was 484. The average number of delays per month thus far is
490. This would result in 5885 delays for the whole of 2016 rather
than 5810 for 2015.
- This
is important because the more patients are subject to delayed
transfers of care – and the data does not specific how long
each of these delays lasted – the fewer beds are available
within hospitals to treat patients who arrive at A&E requiring
treatment. Logically if there are to be more of these delays then
timely performance becomes harder to maintain.
Conclusions and Recommendations
- The
situation laid out above is not a new phenomenon. Difficulties
treating patients in a timely fashion because of a lack of
available beds, has been a feature of the Welsh and other UK health
systems for some time.
31.
This is referred to as Exit Block and can be clearly seen in the
available statistics. From 2010-11 to 2014-15 the number of people
waiting more than four hours in A&E has increased by 29,080 or
26.65%. During the same period the number of people waiting more
than eight hours in A&E has increased by 20,785 or
79.72%.
- Exit
block is proven to be associated with both significant morbidity
and mortality. The latter has been estimated at 3000 patients per
year in the UK.
- Paradoxically
exit block is associated with a greater number of patients admitted
to ‘any bed’ rather than an ‘appropriate
bed’. In turn this leads to greater lengths of stay, reducing
the available bed stock and perniciously increasing the frequency
and severity of exit block.
- Faced
with these trends, and the demonstrable inability of redirection or
re-education strategies to alleviate these pressures, it is more
logical to respond positively to the needs and demands of patients
rather than seek to resist them. It is our opinion that the way to
do this is to put in place the co-location of key out of hours
urgent care services.
- This
can be achieved both physically and through the greater use of
technology such as virtual consultations. This would improve the
quality of care for patients would improve the sustainability of
emergency medicine in the Welsh NHS by decongesting emergency
departments.
- Given
the prevailing situation in the NHS in Wales it would seem unlikely
at this point that performance against the four hour target will
improve. For that to be the case Welsh A&E departments –
and the wider NHS – would need to be adequately staffed and
resourced to meet the demands placed upon it. At present it is
not.
- There
are too few senior medical staff in A&E departments to deliver
effective and efficient care. The attrition rate from UK training
programmes has wasted our most valuable resource. We must ensure
the work environment and shift patterns promote rather than
discourage staff retention.
- Planning
must especially address the need to cope with rising numbers of
attendances by the frail elderly – with complex interactions
between health and social care and long term
co-morbidities.
- Provision
of co-located services within an A&E hub to decongest emergency
departments will deliver a successful strategy that is patient
centred, affordable, efficient and effective.
RCEM
Wales has been campaigning for some time for the reform of
emergency medicine around the elements of our step campaign. If
acted upon this would ensure that A&E were properly staffed and
resourced and improve services for patients in need. Details of
that campaign can be found here:
https://portal.rcem.ac.uk/live/RCEM/Shop/Policy/Campaigns/RCEM/Quality-Policy/Policy/Campaigns.aspx