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Emergency department pressures prompt nurses to consider 'saying no' to patients

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Nurses are divided over whether emergency departments should be able to turn patients away, in the face of rising numbers of attendances and “winter pressures” now extending across the entire year.

During a lengthy discussion at the Royal College of Nursing’s annual congress in Liverpool this week, some nurses said they believed accident and emergency services should be able to “say no” and signpost people to alternative services once they had been triaged.

“Staff around the country are working tirelessly to manage higher attendances and admissions… we need to stem the flow”

Kathy Moore

But others argued that “saying no” would put patients at risk, because they may be deterred from attending or may not have access to alternative services.

Instead, they suggested more money should be provided to support community services in order to help prevent problems from occurring, and also to support more people away from hospital if they did not require emergency treatment.

Introducing the discussion at the conference, Kathy Moore, from the RCN’s Dorset branch, highlighted the increasing strain A&E departments were now under, with more attendances and admissions than ever before and the warning by the Red Cross this winter that the NHS faced a “humanitarian crisis”.

“Staff around the country are working tirelessly to manage higher attendances and admissions. However in order to achieve this we need to stem the flow,” she said, noting that a number of patients either did not require treatment or could be seen elsewhere.

“Until investment is made in the community we will continue to see the backlog”

RCN member

She suggested that, in the future, A&E departments should be part of “hubs” where patients could be referred to and seen by a range of healthcare professionals, including GPs, pharmacists and specialist nurses.

But other nurses at the conference said that healthcare professionals “should never say no to patients”, highlighting that A&E was a service the public trusted and relied upon.

They argued that more money should be spent on prevention services – including immunisation, increased numbers of health visitors to advise families, and mental health initiatives – to help stop people reaching the point where they required emergency care.

“The reality is patients are living longer with more comobordities. Until investment is made in the community we will continue to see the backlog,” said one nurse.

“This is not about ‘saying no’ in ED but about appropriate assessment in ED and redirecting people”

Ellen Nicholson

Others highlighted that a lack of access to out-of-hours services, particularly in rural areas, would leave patients with nowhere to go if emergency departments diverted them.

“When you’ve got no other option, no minor injury unit, no out-of-hours doctors…I always remember when I first started in A&E and someone said to me to ‘at the time the patient came they came because it was the most important thing in their life’, ”said John Hill, from the RCN’s Humber branch.

A nurse working in primary care echoed the call for more funding in primary and community services to help ease A&E pressures.

“From a GP perspective, this is not about ‘saying no’ in ED but about appropriate assessment in ED and redirecting people back to the appropriate service,” said Ellen Nicholson.

Closing the discussion, Ms Moore agreed more funding was required for care in the community. She reiterated that she believed emergency departments were not appropriate for all patients and that “effective triage” could instead ensure they were directed to the right service.

Matter for Discussion submitted by the RCN Dorset Branch:

That this meeting of Congress discusses whether Emergency Departments should be able to say no.

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