There will be a crisis in our NHS in Wales this winter and patients may die on waiting lists”.
This is the message we hear every winter, to the point where – tragically – it has almost lost the power to shock us. It has ceased to be a surprise.
The perennial ‘winter crisis’ in our NHS comes back to a relatively straightforward question. Why does it come as a surprise that in the winter there is going to be a high number of older people being admitted to hospital, and why is it a surprise that there will be a high number of flu victims going to A&E?
These things are predictable, should be predicted and arrangements made. It happens every year. Flu victims should never have to be dealt with by A&E – they should have their own department to go to. It is like a road traffic accident. When the road is blocked, the police find a diversion. Flu victims should have their own dedicated department to go to. Accident and Emergency departments should not be in the position of having to cope with this extra surge in patients, because resources should have been planned more effectively knowing that this was going to happen. It always does in winter.
A big question that nobody seems to want to answer concerns how our A&E departments are staffed. Accident and Emergency departments should be run – on the floor – by well trained, specialist Consultants in Emergency Medicine. A trend has emerged of populating A&E departments with relatively high numbers of junior doctors - we are never given an exact number. These clinicians do tremendous work in very challenging conditions. However, they may not yet have received the training to treat – on the spot - many of the emergency cases that arrive. The net result is that workloads become duplicated as cases end up referred onward to a more senior doctor in a different department. This costs the system time money and resources – and does nothing to benefit the patient. Badly designed, understaffed rotas can also leave junior doctors doing long stretches of night shifts with fewer training opportunities - compunded by the practices of 'weekly on call' and 'hospital by night' which, quite apart from being a huge litigation risk, jeopardise the concept of continuity of care - a bedrock of good clinical governance.
One in Seven patients in Wales is on a waiting list. That amounts to the entire population of Cardiff waiting for surgery. In Morriston Hospital, we know that over 3,100 patients remain on waiting lists for orthopaedic surgery – hips and knees. A single Consultant Orthopaedic Surgeon, operating four times a day, six days a week, would take nearly three years just to clear this list! I know from experience just how frustrating this is for the doctors and the nurses; they will want to ‘get on with the job’ and clear the backlog! Regrettably, it seems unlikely this will happen in a hurry. The burdens on our A&E departments – during the winter in particular – mean that many of our surgeons face the potentially dangerous situation of being asked to work on burgeoning theatre lists whilst simultaneously being ‘on call’. Too often, it is simply not safe for the surgeon to be doing both – so it is time for this practice to stop. At any one time, the surgeon should be either on call, or working on an existing caseload. We need to tackle the root cause of this problem. Our starting point must be a re-evaluation of how our A&E departments work, going back to ‘first principles’ – which also means reassessing the GP ‘out of hours’ services provided in our hospitals. General Practice and Emergency Medicine are distinct fields – it is most efficient when the system works in a way that reflects this. Primary Care clusters - groups of GP surgeries - should be given greater access to facilities such as radiographic testing and the ability to do more complex blood testing on site - A&E departments should not become the standard gateway into the system for patients requiring these tests. There must also be a greater role for community pharmacies – a skilled resource that we must fully utilise.
Exacerbating the issue of waiting lists is the rate of re-admission. The old adage is that ‘prevention is better than cure’ – and there are some practical measures we can take now. Why do we wait until a crisis occurs -such as a fall or a stroke - before our older people have a visit from an occupational therapist to assess the environment at home? It’s a familiar picture. Mrs Jones arrives at an A&E unit in an ambulance, only to find that she cannot be admitted to the unit because there are too many patients already there, waiting for access to a ward bed. Mr Davies, meanwhile, can’t be discharged from the ward because clinicians can’t be sure that his home is properly equipped for his return. It’s a vicious cycle that affects every part of the Welsh NHS. Early intervention would ensure that the patient’s needs remain paramount, whilst saving our health service large sums of money.
There is of course a deeper long-term issue here relating to the way we now train our doctors. We are starting to see the effect of this in our district hospitals, where we are seeing the results of the fragmentation of clinical specialities into sub-specialities, with no extra beds, staff or any infrastructure. We need clinicians, not technicians - this fragmentation means that there are some doctors with too narrow a specialities qualifying through to Consultant level, creating a risk that additional symptoms - indicative of a broader health issue - can be missed. More doctors with the title of Consultant but - less breadth of knowledge in the system,. An ankle specialist may end up knowing very little about knees or hips, for example - so a district hospital staffed in this way could end up failing to detect a serious related condition or indeed underlying cause, thus leading to a subsequent readmission or mortality. Effective medicine treats the whole patient and for this it is vital that areas of general specialities are retained, with the Consultant in charge (who is say, a specialist in the broad field of Orthopaedics) delegating work to a more junior doctor who has this sub-specialities - on the basis of clinical need. It is not only a question of resources, but a question of using them efficiently and intelligently in accordance with a clinical evidence base.
We know the NHS in Wales faces many challenges. By working more efficiently and anticipating problems before they arise, we can go a long way in addressing them. What was once a winter crisis has developed into the winter pattern. To break this we must be pro-active. Prevention is always better than cure.