The arrival of winter has become synonymous with missed waiting time targets, cancelled operations and efforts to redirect people away from accident and emergency departments.
As resilience plans kick in, staff brace themselves for a surge in patients presenting with breathing difficulties and cases of respiratory disease.
“I don’t know how long it can go on for without something radical being done to sort it out”
But this winter was widely described as a “crisis” for the NHS with a range of key pressures converging and warnings that the service had reached a “watershed moment”. How bad was it really – we looked at the data and asked nurses what they thought.
National figures showed 95% of general and acute beds in England were occupied on most days during January and February, and around 93-95% in December.
The figures also revealed 5.5% more attendances to A&E in January compared with the same time last year, though 85.3% were admitted, transferred or discharged within four hours of arrival, compared with 85.1% last year.
- Trusts told to prepare for ‘expected surge’ over festive period
- Deferment of non-urgent patients extended to end of January
- CQC pauses ‘routine inspections’ due to winter pressures
However, services were then faced with February’s cold snap when NHS England praised “dedicated” staff for their work while flu admissions remained “persistently high” and there was a renewed spike in norovirus.
With the possible exception of the so-called “Beast from the East”, many of these pressures are felt every year – and increasingly all year round – but have the past few months been the worst nurses have experienced?
Kathryn Halford, chief nurse at Barking, Havering and Redbridge University Hospitals NHS Trust, which runs King George Hospital in Ilford and Queen’s Hospital in Romford, said: “I have been a nurse for over 35 years and I think it probably is the busiest winter I’ve seen,” she said. “In terms of the patients turning up to the emergency department, we’ve had some of the highest ever at both hospital sites – so the numbers stack up.”
“I have been a nurse for over 35 years and I think it probably is the busiest winter I’ve seen”
The patients have also been more unwell this year, she noted. These two factors have had an impact on bed capacity. It was consistently at 95-100% during most of the “really busy period of two weeks before Christmas, two weeks of Christmas, and two weeks after”, she said.
“Although we always have patients with chest complaints and things, they were sicker so were needing to be in for slightly longer,” she said. “They would perhaps normally be a five-day admission and because they were sicker they were a seven-day admission.”
Barking and Havering reached the second highest point on the NHS Operational Pressures Escalation Levels framework – OPEL 3 – over the weeks surrounding Christmas.
Factors leading an acute trust to declare this kind of alert include a significant drop in performance against the NHS target for 95% of A&E attendees to be seen and admitted, transferred or discharged within four hours. It also can include a significant compromise of patient flow, delays to care due to equipment not being available and “serious” capacity pressures on escalation beds and intensive care and specialist beds.
The OPEL 3 status stayed in place over the entire six-week period, which was unusual for the trust. “Normally you see a decrease in activity coming up to Christmas and we didn’t see that in the same way this year,” said Ms Halford.
It is unknown what caused the influx at that particular time but, as with previous years, many patients continued to use emergency departments instead of their GP service, she noted. Due to the volume of people presenting, at some points, the trust was redirecting almost double the usual number of patients back to primary care.
“We’ve got the lights on all the time, so it’s easy to come to us,” said Ms Halford, regarding why patients continued to attend A&E inappropriately, despite public alerts by hospitals. “You can come to A&E 24 hours a day and be seen very quickly – even if you have to wait four hours. You’d wait that long for a GP appointment,” she said. “We also get a number of people every single day who have been to their GP and don’t like the diagnosis and so come to us to check.”
Hospital trusts have measures in place to mitigate any knock-on effects on patients, such as Barking and Havering’s approach this year of getting people onto beds earlier and carrying out food and additional drink rounds in A&E. It has also increased its use of emergency advanced nurse practitioners, which has sped up the rate at which patients with minor injuries have been seen.
But the pace of work has been non-stop for the trust’s nurses, with even the traditionally quiet periods in A&E – between 3am and 5am – experiencing no let-up, said Ms Halford. “They are having to work very fast all of the time,” she said. “It’s the relentlessness of shift after shift after shift of patients coming through the doors that has been quite tiring for people.”
“It’s really demoralising when time constraints force you into these moral dilemmas”
In spite of the pressure, the team had pulled together, she told Nursing Times, with patients reporting their care was good and no increase in levels of sickness among staff.
However, nurse Louise Taylor, who worked at an Edinburgh hospital this Christmas, said services were so pressured, nurses often had no choice but to spend less time with patients. Based on her experience working bank shifts on general medical wards over the winter, she said nurses were having to make unpopular and difficult decisions.
“It’s a case of there are no beds and no resources, so it means you have to make these moral decisions that you don’t feel comfortable with,” said Ms Taylor, who is currently completing some work in the policy team at the Nuffield Trust think-tank.
“For example, if you have a patient who is able to wash themselves but needs a bit of supervision or prompting, if you are short-staffed and you’re getting pressure from the front door, you have to speed things up,” she said. “Instead of prompting them as you should do, you end up actively having to wash them. If you don’t do that then somebody else won’t get washed at all. It’s really demoralising when time constraints force you into these moral dilemmas.”
During one shift this winter, she said the entire team of nurses were bank staff and only the lead nurse was a substantive hospital employee who had taken on an extra shift. Ms Taylor, who had also previously worked in the department, said they were both constantly asked for help by other staff.
Exclusive: Was this winter really the worst yet for the NHS?
“I did find myself burdened by risk, because people were coming to me asking questions that I felt uncomfortable making decisions on,” she said, describing it as “remarkable nothing went horribly wrong,” due to the fact staff on the shift were “excellent”. “It really could have been a different story if we hadn’t communicated as well as we did,” she said. “We were lucky the patients weren’t as unwell as they could have been.”
While it was now fairly common year-round to work with mainly bank or agency staff on shifts because of staffing shortages, Ms Taylor said she believed the practice happened more over the Christmas because of additional pressures on services in combination with staff holidays.
The pressure from not immediately knowing the patients as well as permanent staff members was added to by having to make decisions about when to discharge patients, she said. “Some of the decision-making is horrible and challenging – discharging patients when you know they’re not ready to be discharged, but you also know there is somebody at the front door who is lying in a corridor somewhere and we need to make space for many people,” she said.
For Liz Alderton, a district nurse who leads a team of 22 in North East London, it was the cycle of patients being moved between the hospital and community that has been particularly problematic this winter. She described patients being discharged when they were medically fit, but not “socially” fit, which meant they soon needed to return to hospital.
Ms Alderton said: “I’ve had a lady who has been in two or three times. She has a chest infection, gets dehydrated, goes to A&E and they give her fluids – she’s actually ok and they send her home but the next day she is not coping again.”
The patient would have benefitted from a short stay to stabilise her condition, but the hospital was under too much pressure to be able to offer that service, said Ms Alderton, who works for North East London NHS Foundation Trust. “Every time she came out she was that little bit frailer,” she added.
The knock-on effect of such a cycle had been more work for the already-stretched community nursing team. Patients with comorbidities would often see other problems worsen, she noted.
Exclusive: Was this winter really the worst yet for the NHS?
“With one patient, she had some atrial fibrillation and was admitted. But she had a leg wound and her circulation became very poor. We went from going twice a week doing her leg dressings to having to go every day,” she said.
“Quite often people go in to A&E and then come out and the problems we are concerned with don’t seem to have been necessarily treated. It’s where people have multiple comorbidities,” she added.
But Ms Alderton highlighted that this was not just an issue during the winter; it was part of a wider problem stemming from patients having more complex health needs and a lack of resources in the community, including staff.
“What we have is a double whammy. We have more people who are sick, who are frail and generally susceptible to ill health, becoming more unwell,” she said. “Then more people are being sent home from hospital because they desperately need the space, and we have the additional problem that we don’t have the resources in the community to help.”
While it is hard to say if it was the worst winter the NHS had faced, nurses said the pressures were increasing but the service would “soldier on”. There was a “high amount of stress and the job gets harder to do” said Ms Alderton.
More investment in hospital and community settings was needed, she said. “I don’t know how long it can go on for without something radical being done to sort it out.”