If you continue without changing your settings, we’ll assume you’re happy to receive all cookies from the BMA website. Find out more about cookies
When you visit any web site, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalised web experience.
Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer.
These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms.
You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information.
These cookies are required
These cookies allow us to know which pages are the most and least popular and see how visitors move around the site. All information we collect is anonymous unless you actively provide personal information to us.
If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.
These cookies allow a website to remember choices you make (such as your user name, language or the region you're in) and tailor the website to provide enhanced features and content for you.
For example, they can be used to remember certain log-in details, changes you've made to text size, font and other parts of pages that you can customise. They may also be used to provide services you've asked for such as watching a video or commenting on a blog. These cookies may be used to ensure that all our services and communications are relevant to you. The information these cookies collect cannot track your browsing activity on other websites.
Without these cookies, a website cannot remember choices you've previously made or personalise your browsing experience meaning you would have to reset these for every visit. In addition, some functionality may not be available if this category is switched off.
Our websites sometimes integrate with other companies’ sites. For example, we integrate with social networking sites such as Twitter and Facebook, to make it easier for you to share what you have read. These sites place their own cookies on your browser as a result of us including their icons and ‘like’ or ‘share’ buttons on our sites.
Last week, Tony Calland and I gave evidence to the Health, Sport and Social Care Committee of the National Assembly for Wales about what more can be done to tackle “winter pressures” in the NHS. This evidence session followed from the written evidence we submitted in September.
The Welsh data confirm that Emergency Department (ED) cases actually peak in the summer months, but that the frail elderly and a rise in respiratory conditions lead to more and different admissions in winter. GPs report difficulties in arranging for patients to be assessed or admitted all year round. Such patients can end up being directed to the ED where they join others waiting for a hospital bed to become available.
At the opposite end of the system patients occupy beds they no longer need, because of a lack of beds in the community, losses in nursing home beds and overstretched social care that may otherwise help patients return to (or remain in) their homes. These ‘delayed discharges’, make the system fit to burst. Operations are being cancelled all year round and the conclusion of almost all those working clinical teams we have talked to is that we have closed too many beds – over 8,000 in the last 20 years.
It is a fruitless task to quibble about definitions and re-classification of what constitutes ‘a bed’; the reality is that, if we had enough beds, we would be able to cope with the predictable, but variable fluctuations in demand that are the natural consequence of ill-health. The last two winters in Wales have been relatively mild, but still we seem ill-prepared, with surgical wards full of medical patients in summer months and why? Here, science helps.
There is a science to queues and people waiting to be ‘served’, seen, dealt with – call it what you will; it is as fascinating as it is complex. Erlang, developed the mathematics in 1908 in relation to the Copenhagen telephone exchange. By our estimates applying this theory suggests that you need about a 20% surplus of beds to deal with unpredictable peaks in demand. Failure to do this results in an increasing queue; it is inevitable. Using modern techniques, computer models run multiple simulations, finding that a bed crisis occurs about 4 times a year when the bed occupancy is 85%, which takes a couple of weeks to clear. Over 90% occupancy, the crises are regular, and take 3 months to clear. As beds have been cut, the occupancy has risen from 78% to 87% in 10 years – the NHS in Wales has simply, calmly and predictably stumbled into a crisis of its own making and the knock on effects are inefficient, costly and prolonged.
It is worth noting, that occupancy rates above 85% are also associated with increased rates of hospital acquired infections (such as C.dif) which increase length of stay reducing discharges further (as well as closing whole wards at a time).
But, it is a mistake to characterise the problem as one only relating to our hospitals heaving with patients fit for discharge with nowhere to go and overstretched EDs. It is clear that there must be sufficient capacity across the entire health and social care system, the right bed in the right place at the right time. This is as much about general practice and social care provision as it is hospitals, yet the focus – and cash – has been focused on secondary care.
Although it is true that we have more complex and frail patients with chronic disease and multiple co-morbidities, most acute care resource is still needed in the last year of life. What is needed prior to this is care – nursing and medical, often multi-agency - away from the acute hospital setting.
GPs in Wales are arranged currently in locality ‘clusters’, where collaboration between several practices can best gauge the needs of the local people. Welsh Government has announced substantial funding to support GP clusters, but many report that the cash isn’t reaching the practices fast enough. Investing in supporting GPs to run services that allow better assessment and keeping patients at home would be an important step in keeping patients that don’t need an acute bed from being admitted and in getting those who do, seen properly, sorted out and discharged in a timely manner.
The frail elderly are not just more likely to be admitted because they are sicker in winter, but they become less able to remain at home in poorly heated housing. We must address wider public health issues, through partnerships with the 3rd sector and better, more efficient, collaboration between primary, secondary and social care.
The quick fix solutions to the current crisis in healthcare provision are expensive. Longer term investments need to be made to adequately tackle the problems, and the financial challenges facing NHS Wales must not detract from these. Welsh Government policy is pinning hope that prudent healthcare and co-production may give the public ownership of their health and how to look after it, but turning intention into tangible benefits is more challenging and it will be vital that changes to our health system are properly evaluated.
‘Choosing wisely’ and getting the right message across to patients to use, not abuse, the correct service they need may help, but the overlap area is the GP out of hours service, which has been woefully under-resourced over the past 12 years. Whether co-located with EDs or stand alone, this service can do much to keep EDs from becoming swamped.
So at the top of the shopping list of those providing care would seem to be to put the beds back into the system – at least until you know what system you are aiming for and that system has been tested to ensure it has the capacity to deal with the fluctuations that occur by the very nature of the business we are in. Helping primary care and communities to keep patients at home or have access to rapid assessment and bolstering a flagging out of hours GP service will help. Additionally, making sure that patients can be admitted and discharged promptly whatever day of the week, will ease the pressure on ED and empty our ambulances promptly, too. You will note that it is not the availability of doctors that is the hold up in a 7 day service, but the availability of social and nursing care packages.
During our evidence session we described hard working doctors, nurses and advanced practitioners trying their best to cope in a system that is geared to them failing because of the predictability of the science of queues. While we wait for those in charge to create the flexible bed capacity we need and for primary and community care to be resourced adequately, we hope that explaining the challenges we all face on a daily basis will help guide the committee to take this issue forward – seeking commitments from Government to make positive changes to how the NHS in Wales is funded and supported all year round.
Dr Philip Banfield is chair of BMA Welsh Council