The solution to hospital bed crises: not necessarily more beds

The problems surrounding the Emergency Department at Antrim Area Hospital have made the news several times this week and led to one general practitioner stating that he would not want to go there as a patient (well no one actively wants to be an A+E patient as no one wishes ill health on themselves but his point is well made).

There are actually two different problems regarding A+E departments which have occurred in the last few weeks. They often occur together but the solutions are different.

Firstly there is the wait to be seen initially in A+E. This is the wait between turning up at the hospital (technically being registered) and then actually being seen by a doctor. The time to be seen by the triage nurse is not counted as it is not part of definitive treatment but only to decide the urgency of the patient. It must be understood that it is extremely rare that patients triaged as urgent or emergency wait anything other than a couple of minutes. As such patients with immediately life threateningly problems do not end up waiting. Other non emergency patients do, however, often end up waiting. The maximum wait is meant to be four hours but at times this is breached (Antrim seem to have been having problems with that this week).

The reasons for the problems with waiting times in A+E are many and varied. People in Northern Ireland do seem to go to “Casualty” more frequently than those across the water and sometimes for trivial problems though A+E attendances are also increasing in mainland GB. Edwin Poots is simply the latest who has tried to suggest
that people go to more appropriate outlets for healthcare such as general practitioners. Clearly, however, if it is easy to get seen within a short time frame in A+E, some people will abuse the system. In addition people may be genuinely worried no matter how trivial their aliment may seem to professionals. As such making A+E departments more efficient and able to see patients faster may actually compound the problem of increasing numbers of attenders with trivial or inappropriate complaints.

In this context Antrim seems to have the problem of being too small for the catchment area it now serves. That itself is the fault of neither Antrim Hospital nor the current health minister. Rather it was known for years that both Whiteabbey and the Mid Ulster A+E departments were likely to close eventually and no long term plans were put in place to expand Antrim in preparation for those closures. When the two smaller units closed (for perfectly good reasons) the Trust did not have time to put plans in place having not been allowed to have such a long term fully announced and detailed plan.

It now seems that there is to be a major expansion of Antrim A+E and that will hopefully allow it to cope with the larger numbers of patients it is receiving. Whether it will future proof the A+E department against the possible closure of Causeway A+E is a further question. Hopefully if that does end up happening it will be properly planned for and everyone told about it in advance. That would be a major departure as compared with the regimes of previous health ministers and would presumably give those opposed to the closure more time to complain. It would, however, be much the most sensible thing to do (if it is decided to close Causeway A+E) and thus far Poots seems to be willing to make sensible decisions even if they are unpopular in the short term.

If one problem is that of too small an A+E department there is a different problem which ends up impacting on A+Es.

In a number of the media reports there have been stories of patients waiting in A+E for many hours as trolley waits and various strategies to avoid counting these people as trolley waiters. A practically identical problem is that of patients who have reached a ward then being moved out of their bed to somewhere else to accommodate a sicker person. The problem impacts on A+E because a patient who is being admitted needs to be found a bed somewhere so that they can leave A+E to go to that bed. The time between a decision to admit and getting to the ward is the “Trolley wait.” If there is no bed for the patient to go to they have to stay in A+E and as such become a trolley waiter.

The obvious answer to this is to increase the number of beds in a hospital. That would, however, not be the best idea.

To understand why not one needs to understand a number of issues:

We have in Northern Ireland more beds per head of population than most other parts of the UK.

Most patients stay in hospital longer than they need to.

We have relatively inadequate access to specialist procedures even in some of our regional hospitals.

What most patients in hospital are waiting for are investigations, procedures, operations or other specific specialist things being done for them. This was well illustrated by one man recounting to Radio Ulster that he waited in Antrim for a week before being sent to the Royal for a heart procedure. All cases are different but if patients such as that are able to have their procedure sooner either in the Royal or in Antrim or indeed anywhere else they can usually be discharged after a much shorter period of time. This would free up a bed and mean that it could be used by another patient who would then not be a trolley wait.

In Northern Ireland we have too few specialist investigations and procedures and far too many general beds. Much more effective and efficient would be to increase the provision of specialist services both in Belfast and roll out the provision of these services to the regional hospitals such as the Ulster, Craigavon, Altnagelvin and Antrim. This has already happened to an extent but not to the degree it has in most of the rest of the UK.

The above would clearly cost money but if done in a planned, phased fashion the gradual increase in specialist services and the increased throughput would allow us to achieve better more rapid patient care with fewer not more beds. It would also increase patient satisfaction as once patients are over the initial phase of their illness the interminable waiting for the next step in their care is one of the greatest irritants to them and their families. People do not want to be in hospital: they want to be returned home to go back to as normal a state as possible as quickly as possible.

As well as at the level of complex specialist care there are apparently basic services which can free up beds. Having social services etc. available outside 9 to 5 Monday to Friday would allow patients to be discharged at the weekend rather than taking up a bed until Monday. A more comprehensive service for providing the likes of intravenous antibiotics and fluids in the community would allow some elderly patients to be adequately treated in their own homes or their nursing homes. Both the patients and their families would much prefer this rather than being admitted to hospital where they are actually at greater risk of more serious hospital acquired infections.

Hence, the solution to some of the problems of lack of beds especially in the acute sector of healthcare provision is not increasing the number of beds but improving the other aspects of care. Indeed counter intuitively if managed properly the changes might well result in less bed shortages at the same time as reducing the number of beds. It is hopelessly clichéd but the health service needs to worker smarter rather than harder.

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  • Excellent post.
    One of the problems is that “GP” situation is not as good as it should be.
    We are a long way from the 1950s/1960s when the family doctor answered a call and drove (often miles) to a patients house.
    Obviously we cannot return to those times……but the “Out of Hours” surgery leaves a lot to be desired.

    In respect of GPs……it is not unuaual to have to wait days for an appointment and even over 24 hours for a prescription.
    Visiting A & E is often a better option and while Minister Poots is absolutely right to say that it is inappropriate in many cases…he has to realise that many people are taking the A&E option and a 4 hour wait is actually in their interests or more importantly their childs interest.

    I have spent the best part of thirty years at our local A & E….to the point where I should be invited to Christmas Staff Party….but the fact is that the “service” has been going downhill for years.
    I have observed people checking in at A & E and reporting that they are not even registered with a GP.
    And as recently as November I sat in the local Casualty Unit with an injured 4 year old child.
    From 8pm until after 3am.
    While I appreciate Triage is difficult..it was absolutely clear from the demeanour (as much as the nature of the injury) of some patients that they would be treated ahead of “respectable” folks.

  • michael-mcivor

    We want to see good clean hospitals back again- there is
    only one way- bring back the Matrons and give them full control again-

  • Crubeen

    Turgon,

    “The health service needs to worker smarter rather than harder.”

    It certainly is not doing that and it’s costing a helluva lot of money not to do that.

    Why do people clog up A&E … apart from those needing urgent heroic intervention? They go because there is nowhere else to go that they can be certain to be seen and treated.

    Why are there so few A&E departments? Everybody wants to practice medicine at the edge of the envelope in the most heroic way possible with the greatest number of tests and interventions so costs of the equipment etc dictate fewer and fewer A&E departments. If, at midnight, blood is spurting from a minor day-surgery procedure that has gone wrong (not uncommon) the patient doesn’t need to attend a major trauma centre – he needs a reasonably competent doctor who can shoot local anaesthesia and thread a needle to stop the flow.

    There’s a joke at the Pentagon that as aircraft costs increase the numbers of aircraft procured decrease and will inexorably reach the point where only one aircraft can be afforded … the Air Force to have it on Monday and Tuesday; the Navy to have it on Wednesday and Thursday and the Army to have it on Friday and Saturday with Sunday reserved for maintenance.

    Health care is heading that way … as you have so expertly pointed out. We soon will have one A&E for the whole of NI and no beds because we really don’t need them, because care in the community is better etc etc.

    Health care is far too important to be left to the professionals in healthcare … it’s long past the time that the long suffering public was given the power to demand the healthcare it wants and needs. In other words, the Health Service needs to be looked at by non-healthcare professionals who would be better placed to construct an efficient and economic model that responded to the needs of the people.

    The service badly needs to be simplified and integrated so as to eliminate duplication and waste. You advocate, for example, a further cost in extending social services’ input to clearing hospital beds. Would this not be better done by Community Nursing without a need for Social Workers? Could the money saved not be better utilised?

    Would it not be better to have Health Centres open on a 24/7 basis providing treatment for minor injuries rather than have over-stretched A&E departments? Considering that there already are after-hours GP services being funded, the cost implications are not great.

  • FuturePhysicist

    more appropriate outlets for healthcare such as general practitioners.

    I have to agree with FJH a bit here, not a real solution to a lack of beds.