What is the problem?
Crowding is a consequence of exit block. This is usually because the acute hospital does not have enough beds to admit their patients.
Before the coronavirus pandemic, Emergency Departments across the UK were dangerously crowded. The number of patient attendances were increasing every year, with roughly a third of these patients requiring admission to a hospital bed.
Crowding in Emergency Departments occurs as a result of reduced resources, namely reductions in beds numbers within hospitals. As a result, many patients received care in corridors, as there are no available beds to admit them to. The pandemic has further exacerbated this issue, resulting in a loss of 10,000 inpatient beds in the NHS in England as inpatient areas need to facilitate social distancing and so can be used less flexibly.
Many patients are being kept in hospital for longer than necessary due to a lack of social care. While medically fit to leave, many patients need help to recover in the form of a social care package, which may not be immediately available. This means that their hospital bed is unavailable to the next patient, resulting in further Emergency Department crowding.
Crowding is inhumane and undignified for patients and puts huge pressure on staff. It also means that staff are less able to provide safe, timely and efficient care to those patients, and any subsequent patients who attend the department. Ambulances then cannot offload, meaning longer waits for these patients. The dual challenge of crowding and coronavirus means there is a further, real, and avoidable risk of people dying from an infection acquired in an Emergency Department.
Health is a devolved matter and key metrics should only be reconsidered in the context of devolved healthcare systems. In England, against the backdrop of dangerous overcrowding and reduced resources, the four-hour target has ceased to be effective as a way to improve performance. There is a perverse incentive to focus on the lower acuity patients, to the detriment of the sickest and oldest patients who need the benefit of scrutiny beyond four hours. In Scotland, the four-hour standard remains an important safety indicator for the acute care system as it has helped to drive safe and effective care, as a result it should be retained.
The Urgent and Emergency Care system in Northern Ireland has faced unprecedented challenges in the past few years. There is an urgent need to restore capacity in the health care system through increasing the numbers of available beds and investing in social care. In addition, in line with the rest of the devolved nations, data on delayed transfers of care must be published regularly in Northern Ireland.
What is the solution and who should take action?
- Across the UK, restore the staffed acute bed capacity to pre-coronavirus levels and increase the bed numbers to achieve 85% bed occupancy in hospitals to maintain flow in Emergency Departments. After restoring bed capacity to pre-coronavirus levels, we estimate an additional 9,429 beds are required in England, 639 in Scotland, and 262 in Wales. In Northern Ireland, a recent population needs assessment revealed that the Urgent and Emergency Care system will require at least an additional 520 beds by 2026.
- Adult social care in the four nations of the UK face substantial challenges and require significant investment in order to ensure patients are discharged safely and promptly when their medical care is complete:
- A. In England, invest £3.9 billion in adult social care by 2023/45
- B. In Scotland, invest at least £1.8 billion into the health and social care service by 2024 to address the funding shortfall and speed up the integration of health and social care.
- C. In Wales invest an additional £1.1 billion in social care by 2030/31 to match demand.
- D. The UK Government should work with the Northern Ireland Executive to provide investment for implementing the Bengoa Review as outlined in New Decade, New Approach.
- Set, monitor, and review metrics that promote patient flow and prioritise care of the most seriously ill and injured patients.
- A. Introduce a metric which monitors and improves ambulance offload times.
- B. In England, replace the 12-hour Decision to Admit metric with a metric on 12-hour stays from point of registration. No patient should need to stay in an Emergency Department for over 12 hours.
- C. The Scottish Government and NHS Scotland should retain the four-hour standard.
- D. Health and Social Care Northern Ireland should regularly collate and publish data related to delayed transfers of care.
- E. Health and Social Care Wales should resume the publication of Health and Social Care data so we can better understand the impact of the pandemic on the NHS in Wales. In addition, delayed transfers of care are not uniformly reported across Wales. A more robust metric is required to encourage patient flow.
- Improve clinician involvement with call handling services. Referral rates drop if there is ready access to an experienced clinician to provide advice.
- Performance standards should be a hospital wide priority.
- Hospital wide acute services need to match service availability to patient need throughout the whole week.
- Internal Professional Standards should be negotiated and delivered.
- Ensure patients can be discharged promptly from inpatient wards throughout the week, focussing on improvements in daylight and weekend discharges.
- Agree and evaluate escalation plans during times of overcrowding with the Trust Board.
EM Clinical Leads
- Advocate on behalf of patients on the harms that are caused by crowding.