Editorial
Authors:   Southampton Foundation Trust Tremona Road Mail Point 520 Southampton SO16 6YD UK, Roseveare Chris 
Published: June 2021

Another year has flown past, winter is back and as usual everyone is talking about emergency pressures in the NHS. Recent months have seen a deluge of reports, proposing short and longer term solutions to the challenges we face. The messages will be familiar for those working in acute medicine, who will have seen much of this before. Indeed, the sense of déjà vu, and apparent lack of progress in implementing those same solutions which have been proposed repeatedly over the past decade is often frustrating. But maybe the tide is now turning. There appears to be an increasing recognition that patient flow is the key to easing pressure at the front door – and this requires action at both ends. The biggest cause for crowding in the Emergency Department (ED) is the inability to move patients into the hospital after the decision to admit, due to the lack of an available bed. Attendances in A&E actually drop in January and February: the increased pressure which arises in winter mainly results from increased acuity of the patients attending (leading to a greater proportion requiring admission) and the increased number of patients whose discharge from hospital is delayed. The hospital fills up, bed moves and ‘outlying’ (or ‘boarding’) of patients adds to the inefficiency and further delays ensue. And the result of this is further pressure on the ‘front door’ – ED, and AMU bear the brunt. So what can we do to make a difference? Clearly there need to be long term solutions – integration of health and social care budgets would help to avoid the perverse incentives which currently prevent timely discharge from hospital once a patient’s medical problems have been resolved; staffing difficulties in acute and emergency medicine require a re-think of the way in which such posts are supported (and perhaps remunerated) to ensure that they are attractive career propositions for future generations of doctors; services, both in hospital and the community, need to be delivered over a 7 day basis to reduce the weekly fluctuations in workload which occur each Monday and Friday; tariffs which currently reward elective work more than emergencies need to be changed to encourage hospitals to prioritise their work equitably. All of this has been said before, and will take time; planning for the future is essential, but we have a problem today which requires more immediate action – so here’s my ‘3 point plan’ to make things feel a bit better for the months ahead: 1. Reset the baseline – start each day with empty beds on the AMU: currently most hospitals are full at 9am each day. We strive to achieve discharges in the mornings, but in reality can never quite get enough patients home in time as new admissions start to arrive. Queues start to build and delays ensue, if patients cannot be assessed in a timely fashion. Resolving this requires us to reset our baseline – modelling the capacity required each evening not just to get through the night, but to do so with a few beds left over in AMU. 2. Stop the ‘waiting’: too many patients stay in hospital simply waiting for things to happen. Community delays may feel beyond our control, but it is important to look inwards as well as outwards. Many delays relate to tests, procedures or speciality reviews which could be done more quickly if systems were better organised. If a patient cannot leave hospital until an investigation is done, and the test will only be done once, there is rarely any justification for that test being delayed. Hospitals need to develop local service level agreements to ensure that overnight stays simply to enable tests to be done become a thing of the past. 3. Deploy staff where and when they are needed: everyone in the NHS is working hard, but there are variations in workload at different times and between different teams within the hospital. Often the busiest times are the times when there are fewest staff available, which impacts on the care which can be delivered to patients and the morale of the staff who are trying to provide it. Training more staff will take time, and filling gaps in rotas with expensive locum staff is not necessarily a cost effective solution. We need to look at the staff we have and ensure that they are being deployed in the most effective way. Workload could be shared more equitably between medical and surgical teams, who could also be deployed to support staff in other clinical areas when operating lists are cancelled due to bed pressures. If a major incident arises, the Dunkirk spirit sets in and staff in all areas of the hospital ‘down tools’ to support each other and the patients affected. There are many days in winter where patient care could benefit from this kind of teamwork. Of course nothing is ever simple – if solutions were easy to find we would have sorted this all out a long time ago, but hopefully the articles in this edition will provide you with some food for thought in the weeks ahead. Wishing you all best wishes for the New Year….