We set a new precedent yesterday in one of our A&E’s. Over 400 patients attended and we admitted over 60 patients in one 24 hour period. This is unheard of – a normal ‘take’ in one of our hospitals is 25 – 30 patients from 200 attendances – yet for the last few weeks we have been routinely admitting in excess of 100 patients a day across our two hospitals.

We set another precedent this week as well – we discharged over 200 patients in two days. That is an astonishing number. Of those 200 discharges how many might you think were discharged to the care of social services? The answer is zero – because those two days were over the weekend shortly after the New Year bank holiday. In the same period the number of ‘delayed transfers of care’ has risen to 70 and the number of ‘medically fit for discharge’ (patients no longer requiring medical care but not safe to go home for other reasons) is another 20 or so on top of that. That’s three (unfunded) wards full.

We are under intense pressure – our staff are performing a herculean task – admitting and caring for the sick – shepherding them through the system – and organising safe and efficient discharge – and keeping the floor in A&E safe – just about. That task involves over 60 different professionals for one patient from the triage nurse at the front door through to the community therapies staff that in-reach into the hospital to pull through patients into our intermediate care facilities via the typically three or four different medical teams that might care for one patient during a hospital stay (A&E team, Acute Medical Team, Medical specialty team, MFFD team) – Not forgetting the critical care team that receive the 5% sickest patients on the way.

Yet we are coping. Whilst we have hit ‘Level 4’ at one or other of our hospitals on a few occasions over this period of ‘crisis’ we have never considered ‘closing our doors’ as some others have. And I am convinced I know why.

Synchronous Coordinated Action

Our hospitals march to the drum beat of the two hourly bed meetings. These are brief (less than 15 minutes), always at the same time (8,10,12,14,16,18,20:00 hrs), teleconferences, involving representatives of every part of the pathway from the front of the hospital to beyond the back door, consistent – run to a script, informative – everyone knows what they need to know and leaves knowing what they have to do (discharge 6 patients, 2 before lunch!). A nurse in charge of a community ward will know what the wait times are in A&E. All the time actions are followed up by the operations centre staff – our ‘air traffic control’.

Control of our Outflow

Just over two years ago our Trust took the strategic decision to – ‘move down the value chain’ – we run community services for over half our population and have developed intermediate care facilities in community locations around our catchment area. We are ‘in control’ i.e. have direct access to nearly 100 community beds – including ‘medically fit for discharge wards’ closely co-located but separate from the hospitals and run by GPs.

This has saved our bacon this winter. Its not been plain sailing – it has taken several weeks to get the ‘drum beat’ working consistently and reliably and there have been times when the acuity of admissions have been such that discharges haven’t happened for the ‘right’ reasons and this has threatened to overwhelm us. We have panned the 4 hour target like everyone else – but we’ve done alright for our patients. I am intensely proud of how well our Medical, Nursing, Therapies, Operations and Community staff have pulled together to pull it off.

Its not an A&E Crisis

A&E waits are a symptom of a failing health and social care system. A&E is the only point of care that is consistently available 24 hours a day. Everyone knows where it is, that its always open, that there will always be a doctor there and that you will get free treatment if you need it. People vote with their feet – other parts of the system are either not trusted or simply not available when needed.

The ‘A&E crisis’ is a consequence of un-restrained inflow and significantly constrained outflow. Neither the ‘inflow’ nor the ‘outflow’ is incentivised or held to account for the demands it places on the hospital. It is being in control of at least some of our outflow that helped us weather this particular storm. And therein lies the solution to the problem – if we want hospitals to ‘succeed’ then they must be in control of the resources of ‘outflow’ services and probably ‘inflow’ services as well.

At the moment the philosophy (if organised thinking is a suitable way to describe it) behind the Better Care Fund (The pooling of health and social care resources) is moving in diametrically the wrong direction on this. BCF is moving resources out of health into social care – on the face of it in order to prevent admission to and promote discharge from expensive hospital care. It will not work – however well meaning – it just won’t. Whilst depleted resource in social care is an issue (and a worsening one) fundamentally the issue is one of accountability and control. As long as the services that provide care before and after hospital experience no cost or consequence for sending a patient to or keeping a patient in hospital then they will continue to behave as they always have done. And as these services gradually fail medical takes in hospital of 60 or more will become the norm not the exception.

2 Comments

  1. Roger,

    Good to hear from you and I enjoyed this blog. Makes sense to me.

    Can you tell us something about the commisisoning/funding apsects of the 100 beds under your direct control.

    Regards, Bruce.

    • Variety of ways – some through our community services contract in Sandwell (Rowley and Leasowes), we also have two MFFD wards (One at City and one at Rowley) which are technically ‘acute’ but run by our comm services with GPs contracted to provide medical cover. We also won a recent tender by Bham City council to run a true intermediate care facility from Sheldon block at City.

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