Dangerous, undignified, costing lives: hospital logjams

Historically the worst is over by February with the busiest months being December and January.

So this looks like a good time to examine the issue, identify where the problems lie, and start working towards a fix before December comes again and the problems mount. Unfortunately, doing this is extremely complicated which in itself helps explain why politicians and others so often call for the wrong remedies.

First, the scale of the crisis. ED waiting time statistics are now available for December – those for January will be released next month. In addition the Department of Health publishes waiting times broken down by hospital which it updates hourly.

In Northern Ireland the target departments work to is that no patient should have to wait for more than 12 hours to be treated, discharged or admitted. Unfortunately last December one-in-five were in that category with a majority (three-in-five) waiting four hours or more.

Dr Paul Kerr, Vice President of the Royal College of Emergency Medicine, Northern Ireland said: “Staff cannot continue to work through adrenaline and goodwill to prop up a broken and failing system. This is the worst crisis we’ve ever had. The figures represent real people who are sick, injured, or unwell and need urgent and emergency care, but the system is providing it to them neither quickly nor effectively. More patients’ week-on-week face long and dangerous waits in crowded departments, corridors, on trolleys, it is undignified for patients and distressing for staff.”

There has been a huge amount of press and TV coverage of the logjams in EDs and, as Dr Kerr observes making sick people wait for treatment is dangerous as well as undignified. But we also need to quantify the harm.

Official statistics are helpful here. When people arrive in the department they are not prioritised in order of arrival, but according to their conditions, and conditions are banded according to urgency. These range from level one, where treatment should start immediately to level 5 which are regarded as non-urgent, where the target is four hours.

Last December 51.1% of attendances were triaged within 15 minutes of their arrival whilst the time taken to triage 95 percent of patients was 1 hour 21 minutes.

The median time from triage to start of treatment in December 2022 was 1 hour 25 minutes whilst 95% of patients started treatment within 7 hours of being triaged.

But the figures do not answer the question about how this affects health outcomes of those concerned.

To do this we have to study academic research. It shows that crowded Emergency Departments translate into longer hospital stays.

Delays in treatment also generate a serious safety concern for patients who may initially appear well, but have a serious underlying cause for their turning up in the department. And overworked staff are more likely to make mistakes.

The Royal College of Emergency Medicine estimates that there were 566 excess deaths in Northern Ireland in 2020/21 as a result of delays in ED. The situation has worsened since.

This December patients awaiting admission were on average spending three hours longer in EDs than they were the previous year, while the non-admitted patient was spending only 30 mins more, suggesting the system is failing the sickest patients the most.

The logjams are not just frustrating for staff and patients, they cost lives.

So what is causing this?

The first thing to note is that the numbers arriving at EDs have not risen dramatically. There are two more important drivers of the chaos, delays and overcrowding. The first is that too many are presenting there who do not need to, the second is that there are far too many patients occupying beds, not because they need them but because the care packages they do need are not available. Consequently others are stuck in EDs waiting on a ward and others stay in ambulances outside the hospital until they can be admitted, which also delays ambulance arrivals for those in need. 

Thus one of the solutions lies not in more money for hospitals, but more investment for social care, which is the teetering edifice on which the entire health service rests.

Currently health trusts are still pursuing a race to the bottom when it comes to adult social care with contracts for suppliers pegged down so that they can only afford to pay staff the same sort of money they would expect for stacking supermarket shelves. The consequence is severe staff shortages and low service levels.

This in turn makes it increasingly difficult for hospitals to discharge people who would be quite capable of living at home if only the right care packages were available.

This can and should be addressed. An expert review into Northern Ireland’s broken adult social care system was published back in December 2017 It famously described the system we still operate today as “collapsing in slow motion” and contained 18 recommendations on what needed to be done.

Subsequent collapses in Stormont administrations have prevented the progress required. The trouble is that as we have shown, hundreds of lives are being lost every year because of one consequence of it – the bed blocking that causes hospital logjams.

Fixing adult social care will cost a lot of money, but we do need to do this. If we don’t the consequences are unthinkable.

The other side of the problem is the numbers presenting at hospital who would be best dealt with elsewhere.

What constitutes an emergency varies widely from one person to the next. They can arise at any time of day or night and can cause fear and panic in patients.

Most of us need guidance. When GPs were easier to access this was quite a straightforward business but as the GP crisis worsens we’ve been unable to rely on getting to speak to one.

The Phone First service is designed for patients who are feeling unwell and considering travelling to an ED with an injury or illness which requires urgent treatment but is not immediately life threatening. It is not available for some but not all out hospitals. The idea is to safely steer patients to the best service for them.

Results of the trials have been encouraging to date. However they are not the panacea sometimes claimed.

England’s equivalent to Phone First is NHS 111 which also assesses acute illness.

On the face of it, it is attractively money-saving. The King’s Fund states that  each 111 telephone consultation costs approximately £11, whereas a GP dealing with the same patient would cost around £39. But NHS 111 employs non-clinical call-handlers using software called NHS Pathways to reach its triage decisions. Pathways cannot make diagnoses, so to minimise risk it funnels around 25 per cent of all cases into the ambulance service or A&E.

This inevitably adds to the throngs in Emergency Departments.

To truly fix the problem, there needs to be budget set aside for people to be signposted where to go for urgent treatment and it what circumstances they should turn to EDs. But ultimately there is no substitute for the guidance best provided by GPs so another way of alleviating hospital pressures would be to fix the crisis in General Practice. And without that, whatever system is used, it is bound to direct more patients than necessary to ED.

Ironically two ways to address blockages in hospitals involve not spending more money on them, but in fixing other parts of the health and social care.

This is very much a world of interdependencies where nothing works in isolation. That fact needs to be recognised before meaningful action is possible.