The Healthcare Professional Will See You in Four Hours Plus

Two years ago I had pneumonia. After three weeks of antibiotics and resting at home my symptoms had not improved. I staggered to see my GP, that Friday morning, and he advised me that I needed to be treated in hospital, there was no more he could do for me and I wasn’t getting any better. Reluctantly I agreed with him and my husband took me to your local A&E. We arrived at 12.00 noon, at 1 o’clock in the morning I received my first dose of antibiotics.

At the time I was so angry and demoralised to be treated like this, as if they didn’t really believe I was that ill, but later I came to realise what had happened, after talking to other people and checking some facts. The whole hospital, not just the A&E Department, were short staffed and having to cope with a large increase in demand. Is it any wonder that the system cracked?

On Monday 28th January, the Government took a step that will make my experience happen more often and to more patients, they announced that they will scrap the four-hour waiting target for A&E treatment (1). The Chief Executive of NHS England, Simon Stevens, announced it the Health and Social Care Committee meeting, on the 28th (2). Matt Hancock, Secretary of State for Health and Social Care, was also giving evidence to the committee at the same time. Simon Stevens said the four-hour target would be significantly altered, political language for scrapped (1).

This has certainly come as a surprise to everyone working in the NHS because no one had been consulting on this, neither the Royal College of Nursing (RCN) or the Royal College of Emergency Medicine (RCEM) were consulted about this (3), the Government just dropped it on us. This isn’t a new idea from this Government, in January 2018 Jeremy Hunted had hinted at this, in the face of the winter pressures on the NHS (4). It seems that the Government is using Brexit, and all the chaos we are facing because of it, to push through something they have been wanting to do for a while.

The four-hour A&E target has been a thorn in the side of this Government for so long. The target is that 95% of patients are treated within four hours in A&E, but in December only 86.4% of patients were treated within this target, and since July 2015 the target has not been met once (3). This has been a constant indicator of how poorly this Government is resourcing and managing the NHS.

The four-hour target was not reached by plucking a number out of the air, but is evidence based (5). It was introduced in 2004, following extensive consultation by the then Labour Government, as a response to overcrowded A&E Departments were patients were faced with long waits for treatment (5). Yet now, when we are again being faced with overcrowded A&E Departments and patients facing long waits, this Government plans to scrap the four-hour A&E target. What is the logic in this?

Targets, when evidence based, have proved very useful in measuring healthcare outcomes and help improve the quality of care. The RCEM, in a report supporting the four-hour target, have found extensive worldwide evidence that time-based targets help improve performance and were associated with reductions in morality (5). This target has also proved useful in highlighting places that are under pressure and strain, but now what it is doing is repeatedly showing how much strain the whole NHS is under, month after month, and embarrassing the Government, month after month.

A&E Departments are under stress for a lot of reasons, not just an increase in demand, but since 2011 there has been 8.8% raise in people attending A&E, this is 23.4million more A&E attendances, or 5,100 more patients a day (6). These increases in demand have not been matched with an increase in resources, which have stagnated since 2010, but there are also other factors putting huge strain on A&E Departments, such as:

- Staff shortages. 10.9% of nursing posts (7) and 7% of doctors’ posts (8) in the NHS are currently empty. These figures are for across the NHS, but this does mean there are far less nurses and doctors available to work A&E Departments. Shortage of staff has been directly linked to poor care. 45% of NHS staff, involved in patient care, have reported that they are too short staffed to deliver safe, dignified and compassionate care (9), and A&E Departments are not immune to this.

- Loss of hospital beds. In the last 30 years the NHS has lost half of its in-patient beds, right across the broad, including medical, surgical, maternity and mental health beds (10). Since 2016/2017, hospital bed occupancy has been running above 90% and regularly exceeds 95% during the winter months (10), which is far higher than the recommended safe limit of 85% (11). The less hospital beds available, the less availability there is to admit new patients, the harder it is to admit patients from A&E, therefore the longer patients have to wait in A&E to be admitted and the four hour target is routinely broken.

- Underfunding of social care. Since 2010 social care budgets have been cut by £7bn and between 2018-2019 they will be cut by a further £700 million, 5% of the whole budget (12). This directly affects patient’s ability to be discharged, because there is less money for home carers, less money for care home funding, less money to adapt patients’ homes and therefore less support for patients living in the community. When there isn’t the social care support then those patients cannot be discharged, becoming delayed transfer of care (DToC) patients, and DToC’s caused by social care problems have increased 130% since 2014 (13). And if hospital beds are being occupied by DToC patients, how can new patients be admitted from A&E?

- Not being able to get a GP appointment. Currently we are short of 15% of the GPs we need, 6,000 GPs (14), and there is a huge difference in the availability of GPs across the country (14). In some areas there is three times the number of patients for each GP (14), making getting a GP appointment far more difficult. The BBC found that only 40% of patients could get a same day appointment (15), 60% were not, while 27% of patients were able to get an appointment within that week. Not all of those who cannot get a same-day appointment will have urgent health needs, but many will, and where can they go when they cannot get a GP appointment? 40% of NHS Walk-In Centres have closed since 2010 (16).

There are a lot of factors that have caused the increase in A&E waiting times and there isn’t one, easy fix to it. Like so much else in healthcare, there are a lot of interconnected factors.

Different NHS Trusts and Social Care Providers around the country are introducing strategies and services to try and reduce A&E attendance. Doncaster has set up a multidisciplinary rapid response team to treat patients in their own homes (17); in Dorset an advanced nurse practitioner acts as a “gatekeeper” to A&E, redirect non-urgent A&E patients to other services where they can be seen (18); at the Chesterfield Royal Hospital nurses have been placed in charge of assessing patients at the children and young people’s assessment unit, therefore streamlining the service and reducing unnecessary admissions (19). But these are only local changes, none of them are national strategies, and it could be even argued that they are only tinkering around the edges. None of them are trying to tackle the reasons behind the increase in A&E demand.

What we need are national strategies to tackle this problem. We need more community services that people can access near to their home when they have an urgent care need (An infection, a wound, a sprain, etc…), which are not just open Monday to Friday, nine-to-five. We need services that enable people to stay in their homes when they are ill or have a long-term health condition, not just social care but much more healthcare being delivered in or near to patients’ homes. I am a Community Nurse, and many of my housebound patients still struggle to get to and from hospital outpatient appointments because there is no alternative. We need to move to a more community-based healthcare system. When I was a student nurse (nearly thirty years ago now) there was a lot of talk about moving us to a community-based healthcare system, and since then that is all there has been, talk. There are some local-based initiatives, but that has been no national policy or political will to achieve this.

In their new NHS Long Term Plan, the Government has promised, by 2023, an extra £20bn in NHS funding, but only £6.9bn will be spent in the community (17). How the are we expected to develop all these new services to reduce hospital admissions with only 34% of the funding? I would say this is a joke but it isn’t funny.

A&E Departments are not coping with the rise demand for their services, which is caused by a lot of factors, and yet this Government’s sole response has been the scrap the A&E treatment target, and therefore remove the one thing that has highlighted the problems in A&E Departments. Do they think that by hiding the problem it will somehow go away? Because this seems all they have done about it.

Managing Brexit is not the only thing this Government seems incapable of doing.

Drew Payne

Boris Johnson and the Art of the Headline Grab

Boris Johnson has never been shy of grabbing the headlines, he has certainly never knowingly turned away from a photo opportunity. When he was Mayor of London, it sometimes felt like all he did was try and grab the headlines, with one stunt after another.

At the end of January the press revealed that Boris would be demanding an extra £100 million a week funding for the NHS, at a Cabinet Meeting (1). That would have resulted in an extra £5.2 billion a year. Now he was quickly slapped down by both Theresa May and Philip Hammond, the Chancellor (2). Since then Boris does been very quiet on the subject, it obviously didn’t get him the good headlines he was after, but it did highlight this government’s failure to fund the NHS or even look realistically at future NHS funding.

This Government has under funded the NHS since 2010. Since 2010, when the Conservatives came back into Government (In coalition then), they have cut the increase in NHS funding to 1.1% (3), after last year’s autumn budget the NHS yearly increase in funding was increased to 1.2% (4). Previous to 2010 NHS funding was increased by, on average, 4% a year since the NHS was founded. NHS funding increases have been cut by nearly 75% and yet demand has not decreased. A&E attendance in December 2017 was up 3.7% on December 2016 (5), and that was just A&E attendance. All areas of the NHS have seen increases in demand, year on year.

This all has had a knock-on effect on the service the NHS can deliver, it’s now failing at all its mayor targets. The four hour A&E treatment target hadn’t been met since July 2015, the 62 day target from urgent cancer referral to treatment hasn’t been met since 2014 and the 18 week target for referral-to-treatment for elective care hasn’t been met since February 2016 (6). Good quality healthcare is not cheap, and repeatedly providing the NHS with below inflation funding increases has a direct affect on patient care. There are no more “efficiency savings” to be made, the fall in funding cannot be absorbed in any other but by cuts to patient care.

The Government had a chance to at least begin turning around this chronic under funding with November’s Autumn Budget. In the run up to the budget there was active campaigning for more NHS funding, at least £4.6 billion to stop the shortfall in NHS funding (6). Simon Stevens, head of NHS England, called for extra funding too, warning that NHS waiting lists will soar to five million by 2021 if its funding isn’t increased (7). Yet when Philip Hammond announced his budget, in November, the NHS only received an extra £1.6 for the next year (8). Officials at the Treasury have leaked to the press that Philip Hammond was angry at all the campaigning for extra funding, especially that of Simon Stevens, and this is why he didn’t provide all the funding the NHS needs (9). I am left speechless with disgust and anger at his petty and vindictive actions. Instead of listening to the reasoned arguments, he followed his ego. What kind of politician is he? Unfortunately he’s typical for this government.

Boris Johnson’s attempt to grab the headlines pushed a much more important NHS policy story out of the back pages. A cross-party group of ninety MPs wrote a letter to Theresa May calling for a cross-party convention on the future of the NHS and care social and the funding they will need (10). The letter was organised by Sarah Wollaston, Conservative MP and chair of the Commons health committee, Norman Lamb, Libdem MP, and Liz Kendall, Labour MP (11). It was signed by 90 MPs from all parties, a third of them were Conservative MPs (11). This was a golden opportunity for Theresa May to tackle the problems dogging the NHS and to do it with the full support of Parliament. This would have provided cross-party support for raising taxes to fund the NHS. So far the Conservative party has shied away from raising taxes, seeming to fear losing political face doing so, but with cross-party support all parties would have taken the “hit”. This was a political initiative that has been long overdue. But Theresa May, in her usual limp-handshake-way, dismissed this call for cross-party action, saying the government were managing the NHS themselves (12). Another typical failure and missed opportunity by Theresa May, and I’ve lost count of how many there have already been.

70% of Conservative voters, in a recent pole, said that the NHS was their main concern (13), and yet this government constantly ignores the problems of the NHS staring them in the face. Even when their own supporters are worried about it, it still doesn’t appear as a high priority for this government. Theresa May does not seem very bothered about it and rarely comments on the NHS. What have we done to deserve politicians so apathetic and uncaring about the NHS? For so many voters, the NHS still remains such a major concern, but to listen to our politicians you would think that there were no great problems with the NHS, beyond a few people moaning about it.

What can we do to finally make this government take the NHS’s problems seriously? Yet another winter crisis in the NHS certainly hasn’t done that (14).

As for Boris Johnson. During the 2016 EU referendum the Leave campaign, which he was the leading light of, claimed that £350 million a week extra funding would go to the NHS (15). Last month Boris only called for an extra £100 million a week for the NHS. So it seems his concern for the NHS has fallen by over 70%. As I said, what can we do to make these politicians take the NHS seriously?

Drew Payne

Is Failure Ever An Option?

Week on week the media is full of stories about failings in the NHS. Two patients died while waiting in a corridor for treatment, (1), a woman died from a brain haemorrhage after there were no intensive care beds available (2), a woman died after surgeons inserted a heart valve upside down (3), surgeons operated on the wrong body part of a patient (4), an NG tube being inserted in a patient’s lungs instead of the stomach (5), and at an A&E Department a patient lay dead for four-and-a-half hours before being found (6).

Previously anyone of these stories would have caused public outcry and would certainly had the nursing profession up in arms and condemning these failures in care, but now these stories barely reach the front pages of newspapers and news websites. Are we no longer shocked by failure?

The NHS is under immense strain, our workload has vastly increased; patients attending A&E Departments has increased by 6% in the last year (7), 193,000 patients a month are waiting beyond the target of 18 weeks for surgery (8), there has been a 3% in emergency admissions via A&E (7), diagnostic tests have increased 5.8%, and consultant-led treatments have increased 5.1% (9). And all this extra demand is having an affect on NHS services. Cancer treatment targets have been missed for the last three years (10), in December and January only 82.3% patients attending A&E were seen within hours (The target being 95%) and in the same time 18,000 patients waited on trolleys of four hours or more to be admitted into a hospital bed (11).

Yet as this demand increases NHS resources decrease, in real terms. The NHS receives an extra 0.9 funding a year (12), and this has been the case since 2010. The inflation rate, December 2016 to January 2017, was 1.6% (13). This doesn’t take into account the extra costs forced on the NHS. Delays in discharging medically fit patients because of no adequate social care (so called “Bed Blockers”) are costing the NHS £900 million a year (14); many drugs have increased in price far more than inflation, prices for generic cancer drugs have risen sharply in the past five years, Tamoxifen and Bulsufan are now 10 times more expensive even though they are no longer under patent (15); the winter crisis we have all lived through has cost the NHS an extra £900 million (16).

But with this increased demand there has not been an increase in staff to meet it, actually the opposite is true. In 2010 there were 8,153 vacant nursing posts in the NHS, 2.5% of the nursing workforce (17), last year (2016) there 21,205 vacant nursing posts, 10% of NHS nursing posts (18). That is a four-fold increase in the number of nurses the NHS is short of, and that is just nurses. It is similar with all NHS healthcare professionals.

There’s more work to do, less resources to meet it and less of us to do the work. It is the perfect storm for things to go wrong. Under this stress mistakes happen, things are forgotten, there isn’t enough time to do everything. But this is healthcare and there is no room for errors or mistakes. If an employee makes a mistake at Tescos the worst that happens is costumers can’t buy their favour sliced bread. If an NHS nurse makes a mistake than a patient’s life could be seriously impaired or even ended.

So why aren’t we more shocked when things go wrong, when patients are harmed or even die? Is it happening so often that we have become numb to it? Are we relieved to hear that it didn’t happen were we work? Are we too busy and stressed to notice?

But the leadership, at the very top of the NHS, seems completely out of touch with what is

really happening in the NHS, the leadership of Jeremy Hunt. In November 2016 Jeremy Hunt issued a statement saying “NHS [has] extra resources to make sure it is better prepared than ever before” (19). At the same time he described calls for extra NHS funding as “misjudgement” (20), ignoring the record deficit in funding the NHS is facing. In January, as the winter crisis was deeply hitting patient care, Jeremy Hunt hinted that the four hour A&E target could be relaxed (21). Shifting the targets to reduce bad news? When the British Red Cross called the NHS winter crisis as a “humanitarian crisis” (22) Jeremy Hunt was nowhere to be found to reply to this (23), over a whole weekend he didn’t issue any statement, he didn’t seem to be working at the weekend. When he finally issued a statement he said that there was “no excuse” for the winter crisis (24), ignoring all the factors causing it. His tone was very much to blame hospitals, and therefore their staff, for the applauding situation. Now in March, the day after the budget which announced extra funding for social care but none for the NHS, Hunt demanded that all NHS A&E Departments must hit their four hour treatment target (25). No extra funding or resources to do this, just Jeremy Hunt demanding it.

How can anyone respect such poor and arrogant leadership?

Jeremy Hunt does not seem bothered by these increasing failings in the NHS, his silence on the subject (Except for the occasional apology when he is embarrassed by the media) certainly says that failure is acceptable to him.

Poor healthcare ruins lives and we should never accept this. We should be shouting from the hill tops, in the streets, in anywhere were people will listen to us that one death because of an NHS failure is NEVER acceptable. Why aren’t we? Or have we grown so tired of this government’s complete lack of concern about the state of the NHS?

With all the pressures, rising demand and cuts to its resources the NHS is under, has failure lost its power to shock? It feels like it…

Drew Payne

And The Truth About Stress

This winter has been very hard on the NHS; nearly a quarter of patients in A&E waited over four hours (1), far less than the 95% target of patients being seen within that time; there were more than 18,000 "trolley waits" (1), patients kept in corridors and on trolleys as they wait for a bed to become available; over 190,000 patients a month waited more than 18 weeks for their surgery (2); at one point 40% of hospitals issued alerts over bed capacity, which happened during the first week in January (3); it has all added £900m to the NHS deficit (4), and this all lead to the British Red Cross calling NHS a “humanitarian crisis” (5).

There has been a lot in the press and on our media about the effects all this has had on patients, there have been many stories of people’s grandparents lying on trolleys for hours on end, but there have been no stories about the stress this crisis has put NHS staff under. Working at this level is physically and emotionally draining, it well certainly take its toll from people. This is busy and stressful work day in and day out, no one day when the pressure eases up (No “slow Tuesdays”), no chance for staff to have an easier day. I have worked in situations like this and I know the physical and mental pressure this puts you under.

Sir Robert Francis QC, who chaired the infamous inquiry into Mid Staffordshire NHS Trust, said that the NHS was only being held together by the “superhuman efforts” of its staff (6). He is right, the extra effort staff have made at work, working above and beyond their required duties is what is holding the NHS together, which has preventing another Mid Staffordshire type scandal hitting the NHS. The RCN (Royal College of Nursing) has found evidence of nurses repeatedly working 12 hour shifts without a break or even without drinking enough water during their shifts (7).  But this situation cannot continue, staff cannot survive under this level of stress. As Sir Francis said: “It can’t carry on like that indefinitely without something going badly, or risking going badly wrong” (6).

How have staff been rewarded for this “superhuman effort”? With nothing!

NHS staff have faced a 1% pay freeze since 2010, as we are repeatedly told that it is patient care or our pay rise (Making it seem we are “selfish” for wanting a pay rise), and in reality our pay has been cut as inflation hits day-to-day prices. In this week’s budget there has been no extra funding for the NHS (8), so no pay rise for NHS staff. MPs received a 1.4 % pay rise last year (9), after they’d received an inflation busting rise of 10% in 2015 (10). This week’s budget did find an extra £2 billion for Social Care funding, but to be phased in over three years (8). This £2 billion has to be shared amongst 152 councils (11) and phased in over three years, this will not relieve the chronic under funding of social care by next winter.  This shortage of social care has caused 10% of NHS hospital beds to be filled by people medically fit to be discharge but who cannot be discharged because there isn’t the social care to support them at home, costing the NHS £900 million a year (12). Yet, at the announcement of this extra Social Care funding, Jeremy Hunt has demanded that all NHS A&E Departments MUST met the four hour target now (13). The Minister of Health, in the face of the “superhuman efforts” by NHS staff, has announced that we HAVE to work harder. Can anyone respect such an arrogant man?

This increased pressure has already had a severe impact on NHS nurses. Janet Davies, chief executive at the RCN, has said that conditions are worse than they have ever been in the NHS (14). Record numbers of nurses have applied for hardship grants just to make ends meet, the RCN also reported (15). The pay freeze forced on nurses is biting hard into nurses’ welfare. But many nurses are already voting with their feet and leaving the NHS. Last year 4,663 nurses requested verification certificates from the NMC (Nursing and Midwifery Council), the documents needed to work overseas as a nurse (16). Since 2011 26,028 nurses have request verification certificates (16). This is just nurses wanting to work overseas. The NHS has a record number of empty nursing posts. As of December 2016, there are 21,205 empty nursing posts in the NHS, 10% of the nursing workforce (17). Between 2013 and 2015, there has been a 50% increase in nursing vacancies (18). There seems no end to this shortage of staff, and all the stress it creates for NHS nurses. Universities have seen a 23% fall in the number of people applying to do nurse training since the Government removed bursaries for student nurses (19). Leading nursing academics have warmed that Brexit could also severely affect nursing numbers (20). There are 33,000 EU nurses working in the NHS (20), if they leave after Brexit (Whether voluntarily due to fears of job security or forced to leave due to post Brexit immigration legalisation) then the NHS will be in a severe crisis.

Whenever Jeremy Hunt has been challenged over the shortage of NHS nurses he has replied with the claim that he has “put” an extra 3,000 nurses on hospital wards (21). Yet 93% of NHS Trusts reported shortages of registered nurses and 78 per cent reported hard-to-fill nursing

vacancies (jobs vacant for three months and longer) (17). How does this equate with Hunt’s claim? Is this just another example of how little he understands about the real situation in the NHS?

I work as a Community Nurse, in a District Nurse team, and our team is made up of approximately 50% agency nurses. This week I have regularly one of only two regular staff on duty (The rest being agency nurses). Since 2012 our workload has over doubled but the number of regular nurses in our team has reduced. These stresses and staff shortages are right across the NHS. I have been a nurse for over 25 years and I cannot remember a time when stress levels were so high and moral was so low in the NHS.

The NHS’s staff are its biggest and most valuable resource, a resource that it should be valuing and caring for. Yet, the Government’s actions this week (The Budget [8] and Jeremy Hunt’s post Budget statement [13]) show how little they are concerned about the crisis affecting the NHS and over stressed NHS staff. On Sunday (5/3/17) 250,000 thousand people marched through London in support of the NHS and against the proposed £20 billion in cuts by 2020 (22). Why didn’t Theresa May, Philip Hammond and Jeremy Hunt listen to them? Is it that they just don’t care about the NHS?

Drew Payne