Vedamurthy Adhiyaman is a geriatrician working is North Wales. He tweets @adhiyamanv
NHS has been in a crisis for a few years now and if anyone thinks it can’t get any worse, they are in for a shock. It is like an overcrowded bus which keeps picking up passengers at every stop where more people get in than that get out. The bus is jam packed with little space to manoeuvre, untidy, and is tipping dangerously.
Despite the assurances from our politicians and bureaucrats trying to downplay the situation, the reality is frightening. Emergency departments (ED) are ever so congested and waiting times exceed many hours. What we used to experience during long bank holiday weekends many years ago, happens every day now. There is no such day as a normal day and chaos and critical bed situation has become the norm.
Patients needing hospitalisation very often stay in the emergency department for hours or even days before getting to a ward. While waiting for a bed, they get moved around very frequently. The situation is extremely risky because the team looking after these patients may be unaware of their whereabouts and many do not get a timely review. Patients who spend the longest in the ED are the ones who are deemed to be physiologically stable and do not fit into any disease specific pathway that would give them a prioritised entry to a ward.
These are often older patients with sudden functional decline. Most of them live alone and would be unsafe to return home with limited social support. Even though the majority of our hospitals have frailty units, they have very limited capacity to cope with the increasing volume of older people living with frailty.
When an ED is overcrowded many core principles are broken. There is very little privacy to examine patients because they are on trollies or chairs in corridors or sat together in small rooms. Very often there is no room to examine these patients in privacy and the small mobile screens do not save any purpose. There is a serious risk of breaching confidentiality when discussions about patients’ conditions occur in the corridors. Facilities to isolate patients with infections in a timely manner are extremely limited. Finding a private room to have sensitive conversations like ceilings of treatment and cardiopulmonary resuscitation could be extremely challenging.
As a result, doctors routinely take the risk of discharging patients home who may not be fit enough to return home, otherwise these patient would spend hours on a trolley in hospital corridors which could be more harmful. Despite this the majority of our patients are still very understanding and do not blame front line staff.
Why are we here? What has failed? The reduction in hospital beds were based on misinformation and drives to cut costs. As a result, in an average district general hospital there might be around 30 patients being cared for in the ED for more than a day and there would be another 30-50 medical patients on outlier wards on any particular day. It is hardly surprising that these numbers would equal the number of beds that the hospitals had shut.
Even though there was enough justification to reduce beds many years ago, we have reached a critical point where we cannot cope with any further reductions. There is still a big myth that we still have too need many beds and the argument is based on the fact that many patients staying in hospitals do not need to be there. Even though this is true, these patients are in hospital not because of medical needs, but due to social care or beds in care homes. These facilities are provided by private sectors on which NHS has very little or no influence.
Even though people the majority of hospitalised patients are successfully managed and discharged home, the journey in this overcrowded bus is unpleasant, unclean, delayed and dangerous. Unless we address the problems with capacity, social care and recruitment, the situation is going to worsen every year and patients and health care professionals should brace themselves for another gruelling winter.