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Winter pressures report 2008/2009. Dr Daniel Beckett. Introduction. Short term (3 month) report commissioned by the Emergency Access Delivery Team (EADT) at the Scottish Government in March 2009 into pressures experienced by NHS Scotland over winter 2008/2009
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Winter pressures report 2008/2009 Dr Daniel Beckett
Introduction • Short term (3 month) report commissioned by the Emergency Access Delivery Team (EADT) at the Scottish Government in March 2009 into pressures experienced by NHS Scotland over winter 2008/2009 • Main driver for this was the drop in performance against the four hour target for access of emergency care
Introduction The Project was commissioned to • Give a clear description of the demands on the system, levels of activity and pressure points over the winter period • Assess the extent to which the system ‘coped’ or showed signs of strain • Describe the aspects of winter planning and system response which worked and which didn’t • Derive lessons for the future, and explore how recommendations may be implemented • Identify the extent to which additional capacity in primary care can improve the effectiveness of the whole system of unscheduled care.
Methods • Qualitative study • 70 one-on-one semi-structured interviews • All 14 territorial boards visited • Hospital management • Chief Executives • Directors of operations • General managers • Bed management • Secondary care clinicians (Clinical leads for emergency and acute medicine) • GP out of hours representatives (managers/clinicians)
Methods • Qualitative study • Special boards • NHS24 • Scottish Ambulance Service • NHS Education for Scotland (NES) • Health Protection Scotland (HPS) • Social work representatives from several boards
Methods • Quantitative study • Data collected by Information Services Scotland (ISD) and Analytical Services Scotland (ASD) • A&E datamart • SMR01 coding • Data also submitted by • NHS24 • Scottish Ambulance Service • ADASTRA Software Ltd • Some data obtained through local enquiry
We asked... • The local health system coped well with winter pressures this year 1 2 3 4 5 6 7 Disagree Neutral Agree • If there were times when the system struggled to cope was this due to predictable or unpredictable factors? 1 2 3 4 5 6 7 Predictable Combination Unpredictable • = GP out of hours = ED clinicians
We asked... • ‘In your opinion and experience, what were the major pressures noted in your healthcare system over winter 2008/2009?’
People said... • ‘It seemed busier this winter’ • ‘Patients being admitted seemed to be older, frailer, and sicker’ • ‘More patients were admitted with respiratory illness’ • ‘Patients admitted over this winter seemed to have a greater length of stay’
The data said • 8% increase in emergency admissions December 2008, 2% increase in emergency admissions January 2009 (compared with 5 year mean) • 11% per week more admissions with respiratory illness compared with winter 2006/2007 • Age profile of emergency admissions similar to winter 2006/2007 • There was no evidence of a disproportionate increase in length of stay of patients admitted over winter 2008/2009
People said... • ‘There are were very few discharges from the hospital over the festive period’ • ‘There were no consultants in the downstream wards’ • ‘Social work weren’t available’ • ‘People were in holiday mode’ • ‘Discharge infrastructure falls apart’ • ‘There is a perception of no pressure on the system as there are so many empty beds over Christmas’
The data said... • Compared to the weekly average for December and January • Discharges week ending 28th December 8% down (and this includes the Christmas Eve surge...) • Discharges week ending 4th January 21% down
People said... • ‘We’ve had problems filling our medical rotas...particularly in the Emergency Department’ • ‘If the Emergency Department is understaffed then they can’t assess people in time and then just rush to admit them’ • ‘The busier the Emergency Department gets, the more patients they admit’
The data said... • Evidence in poorly performing boards that the majority of discharges from the Emergency Department occur after 3hours 45 minutes • There was no evidence that as activity in Emergency Departments increased the proportion of patients admitted increased • The converse may be true in well staffed departments
The data said... • Well recognised shortage middle grade medical staff in many acute specialities • Emergency medicine/Acute medicine • Acute surgery • Obstetrics and Gynaecology • Paediatrics • FTSTA posts impossible to fill/no locums • Not all due to MMC... • Some NHS Boards already trading in funding for unfilled FTSTA posts for new consultant posts
People said... • ‘System Watch isn’t helpful’ • ‘It’s too complicated’ • ‘It counts conditions not relevant to medicine’ • ‘System Watch just isn’t accurate enough for a small board’ • ‘What’s System Watch?’
People said... • ‘This board has no problems with delayed discharges either under 6 weeks or over 6 weeks’ • ‘Our biggest problem is delayed discharges’ • ‘Up to 50% of our delayed discharges aren’t reported to ISD because of coding washout’ • ‘We use code 9 – complex case – imaginatively’
People said... • ‘We couldn’t get people out to Community Hospitals’ • Unavailability of Patient Transport Services (particularly at short notice – for example from the Emergency Department) • Complex (and sometimes archaic) referral processes • Patient choice
We also asked... • ‘What worked particularly well in your health system over this winter?’
People said... • ‘Staff worked bloody hard’ • ‘The festive periods were well planned for’ • ‘GP out of hours planned well, and it worked well’ • Lots of other things – read your ‘Examples of good practice document’!
The data said... • In one board, GP out of hours activity increased almost 30% from summer 2008 to winter 2008/2009 • Despite this there was no discernible difference in the performance against the primary KPI over this time • Compare this with only an 8% increase in Emergency Admissions to Hospital from summer 2008 to winter 2008/2009
Anything else? • Some boards voiced concern that the 18 week Referral to Treatment Target was being prioritised above the four hour emergency access target • Surgical wards remaining closed despite 8 hour trolley waits in the Emergency Department • Waiting list initiatives on 5th January with high levels of unplanned medical activity predicted • Loss of corporate memory since the disbanding of the UCC
Anything else? • Lack of clarity in some boards regarding escalation plans • Some reports of misuse, and others of deliberate refusal to escalate • Variable input from Community Health Partnerships • Clinicians disengaged from bed management issues
Anything else? • Boarding patients (aka outliers, decants and sleepers) • Used as a solution to capacity issues over winter 2008/2009 in all 11 mainland Health Boards • Some boards have made big improvements (reduced 70%) by actively managing LOS • In other boards 20% of medical patients were boarded at any one time, occupying >10% of the total hospital bed capacity • Increasing move to board from AMU (and the ED)
Conclusions... • Staff worked hard! • Winter pressure is something of a misnomer – there are few winter specific problems – but overall activity is increased and weak areas in the system are exposed, particularly during surges in demand • There is no single reason why NHS Scotland failed to deliver the 98% target over winter 2008/2009, but commonalities exist between boards to allow recommendations to be made
Recommendations • Health Boards should ensure that their winter planning starts early and that the process includes Community Health Partnerships and Social Work Departments. There should be a clear relationship between the winter plan and pandemic flu plan. • Integral to the winter plan should be the escalation plan. This should involve all stakeholders including Community Health Partnerships. This includes the utilisation of beds in Community Hospitals, and protocols for referral should be agreed now, dealing with any challenges regarding perceived bed ownership
Recommendations • Boards should undertake more accurate modelling over the festive period to plan elective capacity and optimise the use of bed capacity. This may then enable hospitals to reduce the number of elective admissions on the first Monday in January. Further consideration should be given to front loading the first week in January with minor procedures, and back loading with majors. Also medical elective activity (such as clinics and endoscopy lists) could be back loaded during this week.
Recommendations • System Watch should be used systematically for long to medium term predictions of unscheduled activity, and those predictions should be acted upon to create the required capacity, both in terms of beds and to support initiatives to avoid admission. Consideration should also be given to the use of System Watch for planning of elective activity over the winter months.
Recommendations • The level of discharges over the holiday period should be improved. This might include: • increased consultant presence with dedicated discharge ward rounds in downstream wards • utilisation of a rapid response team (or equivalent) of AHPs with access to homecare packages without recourse to social work assessment • re-energising and establishing ownership of the Estimated Date of Discharge policy, plus introducing Nurse Led Discharges (NLDs)
Recommendations • If all the above measures have been undertaken, including consultant review and discharge of downstream patients, and all capacity beds filled (including community beds) then the 98% standard for emergency access of care should be achievable • If ongoing difficulties then priority should be given to emergency admissions over routine elective procedures • The Scottish Government has, for the last 10 years, made it clear that clinical decision making always trumps routine elective targets.
Recommendations • Boards should work towards eliminating the boarding of patients as a solution to bed capacity problems. Specifically, the boarding of patients from the Admissions Unit and/or Emergency Department should never occur.
What have I learnt?... • Scotland is a very big place • No two Health Boards think they are the same... • Never trust Professor Bell if he rings up asking if you want to ‘help with a little bit of research...’ • That it’s impossible to fit 3 months of work into 30 minutes so email me any time for more information • dbeckett@doctors.org.uk • Full report (82 pages) out next week... • Thank you!
