Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon
Health, Social Care and Sport Committee
HSCS(5)-06-16 Papur 2/ Paper 2
WINTER PREPAREDNESS 2016-17
Inquiry by the National Assembly for Wales Health, Social Care and Sport Committee
Response from BMA Cymru Wales
9 September 2016
INTRODUCTION
BMA Cymru Wales is pleased to provide a response to the Health, Social Care and Sport Committee’s inquiry into winter preparedness 2016-17.
The British Medical Association (BMA) is an independent professional association and trade union representing doctors and medical students from all branches of medicine all over the UK and supporting them to deliver the highest standards of patient care. We have a membership of over 160,000, which continues to grow every year. BMA Cymru Wales represents over 7,500 members in Wales from every branch of the medical profession.
RESPONSE
Executive Summary
Causes of winter pressures
Winter pressures are caused by the interplay between seasonal increases in morbidity and structural problems within the healthcare system. An increase in winter mortality and morbidity does not just occur during extremely cold weather, but also on relatively mild winter days, which are more frequent. The cold weather mainly affects the health of older people, the very young and those with long term conditions. This, combined with the dangers associated with snow and ice and the sheer scale of the annual influenza vaccination campaign, leads to increased pressures on the health service during the winter season.
The exact pattern of winter pressures is largely unpredictable, mostly because it is impossible to predict the severity of winter weather or of any flu outbreak. As a result of this, the health and care system must have adequate capacity and plan appropriately to be sufficiently robust to react to these necessarily variable demands. However, NHS Wales is already stretched to its limits and increasingly unable to respond to additional pressures.
Unfortunately, these public health pressures impact significantly on emergency departments, generating severe challenges in bed access throughout hospitals. The declining number of hospital beds, workforce shortages and patient flow must all be addressed if emergency departments are to have sufficient capacity to cope with winter pressures.
The surge in morbidity during the winter months also has a major impact on primary care. General practice is going through an unprecedented crisis and must be given the resourcing and support needed to respond flexibly to the needs of patients. This includes further promotion of self-care, which can help reduce demand on over-stretched practices. Emergency departments are also under resourced. Combined, these pressures put the healthcare system under huge strain, reducing its ability to absorb spikes in demand during the winter months. Emergency departments must also not be considered in isolation – there needs to be greater collaboration, coordination and integration between all areas of the health and care system.
While there will always be winter pressures, it is possible to create a health system that is sufficiently robust to react to the inevitable but variable additional demands placed on services during winter. However, there is no quick fix solution to the current crisis in healthcare provision. Longer term investments need to be made to adequately tackle the problems, and the financial challenges facing the NHS in Wales must not detract from these.
The complete solution is even broader. In order to truly manage winter pressures, we will need to tackle wider public health issues – such as keeping our older and vulnerable population warm in winter, keeping them well fed, keeping them mobile, and ensuring timely access to adequate social care.
Planning for winter pressures and developing resilience within the system
The Welsh Government holds quarterly, seasonal planning meetings with the NHS, local authorities and the third sector. Health boards, local authorities and the ambulance service have also developed joint winter plans over the last two winters.[1] Through the Environment (Wales) Act 2016 and a focus on energy efficiency, coupled with Warm Homes programmes including NEST and Arbed, progress has been made in tackling some of the root causes of health problems in winter that are related to or exacerbate by living in cold conditions.[2] ‘Flu vaccination programmes aimed at particularly vulnerable groups have been proactive and had a reasonable take up (although under the Welsh Government target).[3] However, despite these interventions, the number of excess winter deaths has increased significantly in the last decade, and this year on year decline shows little sign of stopping.
In Wales there are on average between 50,000 and 70,000 attendances at A&E departments in any given month.[4] During winter months there is usually an increase in emergency admissions which places the health service under significant strain. Emergency admissions primarily increase because of a rise in the number of respiratory infections, which mainly affect the very young, elderly and those with co-morbidities. Problems can also derive from the length of time patients with these complex and severe conditions stay in hospital.
An increase in emergency admissions puts pressure on hospital services, and adds to the existing challenges within the NHS in Wales. One of the most pressing challenges with regard to coping with winter pressures is the gradual decline of the number of available hospital beds, as a consequence of an increase in the number of day case admissions and an increasing tendency to try to treat patients in a primary or community care setting. The decline in available beds impacts on patient care within hospitals, particularly during winter, and is counterproductive to the provision of optimal care.
BMA Cymru Wales has raised concerns about the steady decline in the number of available beds over the last decade and the impact this may have on the safety and quality of patient care. We would like to see this policy urgently re-evaluated. The lack of availability of appropriate hospital beds can result in patients being admitted to any available bed, not necessarily within the ward they need. Data from StatsWales clearly shows that the number of available beds has decreased year on year from almost 20,000 in 1999 to around 11,000 in 2015.[5]
At the same time, our members report that demand has increased and this has pushed the more efficient use of fewer beds beyond the limits of safety – with higher bed occupancy rates, increased bed use factor, reducing length of stay and reducing turnover interval. These factors adversely affect patient cross-infection rates and reduce staff to patient ratios resulting, in our view, in avoidable harm and increased staff sickness.
For some decades now, this downward trend in bed capacity has exceeded the level which might have been safely removed from the system due to the demonstrable increases in efficiency that have taken place. As a result, the NHS in Wales is now provisioned in terms of bed capacity for a slightly-better-than-average day but not for an average winter’s day. There is therefore no longer any potential resilience within the system for a worse than average day, or series of days
Social care and delays in the transfer of care
Wales’ aging population has a significant impact on demand for health and social care services all year round, but particularly during winter. Generally we know that the number of elective and non-elective hospital admissions for older people has increased. During winter the number of emergency admissions increases further. The complexity and severity of conditions of those who are admitted places a huge strain across emergency departments.
In order to better cope with increased demand it is vital that social care services also have sufficient capacity and investment. BMA Cymru Wales is concerned that a lack of funding and capacity within social care is increasingly impacting on the provision of healthcare, with patients presenting at healthcare settings due to gaps in social care provision. This also manifests itself in delays in the transfer of care from hospital settings for older patients which can result in significant financial strain on the NHS and exacerbate problems at times of increased demand.
We are aware of cases where GPs may wish to refer patients for nursing care rather than admission to hospital but, because it may not be possible for suitable care to be arranged in a timely manner, GPs have had no alternative but to arrange for their patients to be admitted to hospital. This adds to pressures on the availability of hospital beds which in turn leads to delays for patients who need to be admitted to those beds following presentation at emergency departments.
Good collaboration between health and social care services is important to avoid this happening. Hospital discharge should be a timely, planned and co-ordinated process and communication with families, patients and carers is of fundamental importance throughout. This is especially important during winter months when, due to the weather, patients with co-morbidities will be more vulnerable.
Medical workforce
In order for the health system to be sufficiently robust to react to seasonal pressures, there must be sufficient recruitment to all specialties within the NHS in Wales. We have concerns that there are a significant number of trainee vacancies within Wales although there is insufficient data to fully understand such workforce issues.
There are many areas where there is a paucity of data available compared to that available in England. For example, there is a distinct lack of collection and publication of meaningful data on workforce vacancies. This has not been routinely published in Wales since 2011. Insufficient data evidently hinders effective workforce planning.
The Welsh Government often focusses on the fact that the total number of GPs in Wales has risen over the last few years. These figures only relate to a headcount of GPs working in Wales. A more accurate figure would be the number of whole-time equivalent GPs but this information is not collected. It is evident that an increase in the number of GPs does not necessarily mean more capacity within the workforce or more appointments available to patients, as so many GPs now work part time due to the pressures and stresses they are facing after years of inadequate resourcing of general practice.
The small increase in headcount also fails to reflect the significant changes in working patterns for GPs that have taken place over the last 12 years. This has led to a level of workload that is becoming increasingly unsustainable across Wales, with even more acute problems in certain areas.
It is vital for the quality and sustainability of the service that simple measures such as a headcount are avoided as they do not accurately reflect the complex factors affecting the stability and appropriate skill mix of the workforce.
Most patients enter the healthcare system through general practice, which has seen an unprecedented increase in demand in recent years alongside significant, and growing, workforce shortages.
Given the significant challenges we are faced within Wales, BMA Cymru Wales welcomes recent announcements from the new Welsh Government of plans to increase the number of GPs and primary healthcare workers in Wales through training and recruitment. However, we believe there is still much to do to address the current crisis in general practice, the effects of which will be exacerbated during winter.
Based on figures from 2013, we know that GPs in Wales carry out in excess of 19 million consultations with patients per year. On the basis of studies undertaken within the NHS in England, through which it has been generally accepted that around a third of GP consultations are unscheduled, this means that GPs in Wales undertake more than 6.5million unscheduled consultations a year – significantly more than those dealt with through accident and emergency departments.
In order to ensure patient safety, and to protect GPs against burnout, it is crucial that action is taken to provide for both an increase in recruitment and put in place appropriate support and safe working guidelines to prevent unsafe practices. Unmanageable demand for primary care will inevitably lead to patients presenting at accident and emergency departments, adding to existing pressures.
Self-care
Self-care plays an important role in helping to reduce demand on over-stretched primary care and emergency departments during periods of increased demand. Self-care can prevent ill-health in the long-term, and can help reduce the burden on general practice in winter. However, increased use of self-care and its promotion should only be one of many measures taken to increase the resilience of NHS Wales to beat the effects of winter pressures. Self-care alone is not sufficient to address the problems experienced by the NHS in Wales in winter.
Further to this, there is a distinct need for a public education programme to support people to make appropriate choices as to how and when they access healthcare. It is important that people understand when it is appropriate to access unscheduled care through either their GP or their local accident and emergency department. More work needs to be done to understand behaviour patterns and to work with groups who are more likely to access care inappropriately.