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Hike in A&E trolley waits driven by 'perfect storm' of nurse cuts and bed shortages


Financial pressure and a lack of nurses is leading to increasing overcrowding in accident and emergency departments, it has been claimed.

The warnings come in response to a Nursing Times investigation, which found the number of patients waiting up to 12 hours for a bed has rocketed by nearly a third in the space of a year.

During the first six months of 2012 66,845 patients waited between four hours and 12 hours for a bed once a decision had been taken to admit them, analysis of Department of Health data revealed. This is up from 50,944 in the same period the previous year – a 31% rise.

Nursing Times’ findings support the results of a survey by the Royal College of Nursing earlier this year, in which half of A&E nurses reported that patients were receiving care in corridors or other inappropriate areas at least once a day.

Tim Curry, RCN assistant head of UK nursing, blamed the increase on a “perfect storm” of rising patient expectations, financial pressure in the acute sector, and distractions caused by restructuring and reform in the primary care and community sector.

He said while it could sometime be appropriate for patients to be managed in A&E – for example, if they were waiting for diagnostic tests – the scale of the increase was “startling”.

“You need skilled nurses and vacant beds, and both of those are under huge pressure. Making contact with district nursing teams is also harder at the moment,” he said.

Mr Curry called for more trusts to give nurses the authority to discharge patients in order to improve patient flow.

The main A&E performance measure currently used by the DH and Monitor, the foundation trust regulator, requires trusts to admit or discharge 95% of A&E patients within four hours.

Nursing Times assessed trusts using the old “trolley wait” target used by the government in the early 2000s. Trusts were judged to have failed if 5% or more of all emergency admissions waited more than four hours for a bed.

Using this measure, 27 of the 146 trusts analysed were found to have under-achieved during the first six months of 2012, up from 14 in the same period in 2011. A change in how the DH publishes A&E performance data halfway through 2011-12 prevents full year-on-year comparison.

College of Emergency Medicine president Mike Clancy told Nursing Times the rise in patients waiting longer to be admitted was a reflection of the pressure on hospital bed stock.

“It’s a high pressure system and small changes in demand make a big change in waiting. We are asking wards to handle more patients faster,” he said.

“There is quite clear evidence that with overcrowding goes increased mortality and morbidity. There is a real patient safety issue.”

Mr Clancy said there was anecdotal evidence that A&E attendances were increasing during periods that were harder to staff, for example evenings and weekends. He said this was being exacerbated by difficulty in recruiting to emergency departments.

A spokeswoman for Wye Valley Trust, which the investigation found had a high proportion of patients waiting more than four hours for a bed, said its figures had been affected by the introduction of a clinical decisions unit.

This had increased the number of patients managed in A&E without going onto a ward while also reducing overall length of stay for some conditions.

Matthew Cooke, the DH’s national clinical director for urgent and emergency care, told Nursing Times this kind of change in practice was likely to be driving the trend, along with the changing patterns of demand, such as more patients presenting in the evenings and at weekends.

“We have to keep working to make sure our staffing levels match the demand,” he said.

A spokeswoman for Surrey and Sussex Healthcare, which was found to have the highest proportion of patients waiting for four hours or more over the period, said performance had recently improved.

She said the trust was refurbishing its A&E to increase capacity, had added 40 beds in new wards and recruited more consultants. This had already led to an improvement, with 99.4% of patients seen within four hours in the week ending 20 May.

Meanwhile, a change in patterns of demand was one of the factors behind a doubling in the number of patients waiting more than four hours for a bed at Northampton General Hospital.

Its chief operating officer Christine Allen said the trust had completed a refurbishment of its emergency department to increase capacity in May, recruited more staff and matched staffing to the times of day with most demand.

She said: “We have done all we can in terms of creating capacity, but what we now need to do is work with our commissioners to improve the urgent care pathway from primary care right through to discharge from hospital.”


The longest waits


Readers' comments (15)

  • Over the last 12 - 18 months we have experienced a 10% increase in the daily attendance. We are also experiencing staff shortages such that there are high numbers of agency staff. The number of beds has been drastically reduced. However simply increasing the size of and increasing the staffing in the ED without increasing hospital capacity will not solve the problem.

    Imagine you are working on your computer and it is getting slower and slower because the discs are getting full. Nothing can be done to speed up the computer until either you delete something off the discs or you change the size of disc storage available by adding another disc.
    This is exactly what is happeniong at the moment in hospitals, fiddling with the periphery of the problem, changing the 'processes' for example, hoping that it will improve things; when in fact more 'disc space', i.e. beds, is what is needed. Until this is sorted out then the problem will remain and only get worse. Historically and geographically this is an ongoing problem both locally and worldwide.

    This is a systemic problem not an ED problem or a primary care problem it is an NHS problem.
    There needs to be a systematic, systemic top down and bottom up review of the WHOLE process not just the ED/Urgent Care portion.

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  • seems more adequate 24 hr GP services are required to reduce the load of non-emergencies on A&E.

    Why not have 'permanances', 24 hour walk in clinics across the country which are fully equipped to deal with all but the most emergencies which would also free up A&E from all but the most serious cases requiring specialised equipment and care.

    Why not have dedicated centres for mental health support and emergencies and other specialised services for those suffering from substance abuse?

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  • welcome to your new tory nhs!!

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  • These problems were entirely predictable, from the recent changes in the NHS.

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  • Anonymous | 14-Aug-2012 10:50 am

    so why was it allowed to happen?

    it seems everybody could have predicted it except those in charge instigating the changes!

    somewhere along the line there is a problem.

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  • I agree with 09.40- the NHS is structured around the needs of doctors rather than the needs of patients- GPs work 9-5 (largely) and hospitals which are 24hour organisations have staffing levels determined largely by doctors hours and availability rather than matching to need. The comment about primary care stepping up is valid- 20th century model- needs bringing into the 21st century

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  • I agree with the first anon. This is a systemic problem across the NHS, not just ED's or A&Es. Growing population + shrinking NHS = MASSIVE PROBLEM!!!!

    But it doesn't have to be. It's hardly rocket science is it?

    Stop shuting down all the wards/hospitals and actually open more!

    Double the numbers of nursing and medical staff on any given ward/department/shift AT LEAST!

    And have ALL essential services run 24 hours! Why is it that nurses seem to be the only ones who do this?

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  • I think there needs to be a massive rethink on patient care as a whole. We have patients waiting residential/nursing home placement that block beds, this is due to homes being closed. Those waiting POC, there are not enough staff in community to facilitate this, again, they block beds when medically fit. Mental health patients, the overdoses, intoxicated patient, all have to medically fit before seen by psych, so again sat waiting in an acute bed, why have services been taken away from mental health, with the country in recession, overdoses have increased massively, but we can not cope with them, there should be better facilities for this group of patient in a more appropriate place. In ED, there are people that go there because they can't see their GP during the day so go to ED after work, why not have out of hours GP in every ED dept to take minor complaints away from ED. In my ED, we had a patient wait more than 4 hours as he had apple skin stuck in his tooth!!!! Do we not have a right to refuse patients that are not an emergency or accident!!!! They should be redirected to a more appropriate place. Have a walk in centre, GP out of hours and ED all in the same building and at reception/triage, you get told which dept you will attend. I think for non emergency attendees to ED, a small charge to pay, they will soon stop coming! Anyway, my rant is over, have a good day

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  • Anonymous | 14-Aug-2012 11:45 am

    from 09.40

    I agree with your comment too. much of our infrastructure for all services in the country, not only healthcare, date from way back (some even pre-Victorian) to a very different sized population and with very different needs from now in the 21st century but nobody has had the foresight to adapt them adequately to keep them up to date so now they are so broken it would take a miracle to find adequate resources to put them right. it is the same with many of our laws and instead of updating them and enforcing them we have spent precious financial resources dabbling in other things and other countries' affairs and trying to keep up with EU laws many of which appear unsuited to our own particular circumstances.

    If we look at some of the other countries in Europe it can be seen that despite higher standards of service they continue to invest in them and strive continuously for improvements to keep them up to date to meet the demands of a growing public and their most recent and changing needs. This is the only way.

    Britain has really shown their worth to their own citizens and the rest of the world in what they are really capable of. it just requires some extra effort to apply all their hard work and include everybody else in it to improve all our services and provide for our future and that of the generations which will follow. nobdody wishes to inherit an indebted and broken down country which gives them little hope and inspiration on which to build their own futures.

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  • As everyone has said its a problem with no space and more people, the problem is that the senior mangers run round with Mr Langsley smiling and agreeing with him instead of standing up to him and telling him how it really is, and that is the cuts to the NHS is killing it, nobody wants to work for an employer that wants them to work longer for less pay and conditions, the NHS is dieing on it feet. the problems are only going to get worse unless the cuts are stopped.

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