The solution to the A+E problems lies outside A+E

The travails of the NI NHS are back in the news and specifically the problem of A+E: except it is not actually all an A+E problem. The main problem is the long waits in A+E of 12 hours or more.

It must be understood that these people are not a waiting initial assessment and treatment but rather are awaiting admission to a ward: their A+E stay and treatment should have already finished. These people are entirely inappropriately being treated in A+E on trolleys, in assorted side rooms etc.

The A+E department is not the appropriate place for them to be treated and the staff there are too busy with the latest admissions (and the need to keep to the four hour initial treatment standard) to give the trolley waits the time they need.

The solution is to move the patients to beds in appropriate wards but ironically the solution is not necessarily to have more beds. The problem is that the beds in the wards are frequently full of patients awaiting further investigations, tests and treatments which need to be performed on that admission though not necessarily immediately.

The easiest way would be to use an example. If a patient is admitted with a bad angina attack / mild heart attack most of them will need an angiogram (the dye test). Some need this immediately as a life and death emergency but most do not. Frequently people in Northern Ireland wait for days for such an investigation: they come to no harm from this wait but they do occupy a bed.

However, if they had the angiogram within the first day or two they could be home by day three: preferable for the patient but of most relevance for this discussion freeing a bed for someone else. Exactly the same issue pertains for all sorts of other aliments. Getting patients their investigations and treatments earlier allows them to be discharged sooner and creates a bed for someone otherwise waiting on a trolley in A+E.

Sue Ramsey of Sinn Fein gets this point right at the very end of this piece though I am unsure if she draws the correct conclusions from it – to be fair she does not get the time to draw conculsions:

The problem then is not increasing the size of A+E or the numbers of A+Es (that latter option might well be actively counterproductive though minor injuries units have great value). It is not even increasing the number of beds. Rather it is addressing the bottle necks in the system.

These bottle necks waste patients’ time and keep them inappropriately in hospital which can actually be dangerous for older, frailer patients who more easily catch potentially life threatening illnesses in hospital.

Increasing access to these investigations, however, takes money to buy the equipment and most importantly to staff the relevant theatres etc. It would also be potentially sensible to contemplate semi routine work beyond normal office hours.

The BMA have been considering this regarding hospital consultants but consultants alone are not the solution. Most decisions a consultant makes or procedures a consultant does require a team that means consultants, junior doctors, nurses, radiographers etc. etc.

Thus far Poots has made sensible suggestions of allowing senior nurses to discharge patients at weekends and trying to ensure patients can be discharged in the morning. Currently it is remarkably difficult to discharge a patient in the morning for assorted reasons which usually look fairly spurious.

The other issues around increasing procedures etc are potentially more problematic. Larger centres can more easily run later and at weekends as they have a larger pool of staff. Yet again it comes back to the fact that we need a smaller number of hospitals performing more state of the art procedures, more frequently, at times outside normal office hours.

This is safer and better use of resources and provides patients with what they want: namely more chance of getting better and getting better more quickly. All health ministers both direct rule and local have repeatedly shied away from admitting to the need to close hospitals.

To be fair in GB the battle to rationalise the hospital estate has been almost as long and hard with assorted daft appeals to historic names and places of the past. There has also been the inevitable shroud waving that people will die unless there is a hospital less than 30 minutes away; not worrying about the facilities of the unit nor the frequency with which procedures are performed by it.

Poots seems to be willing to contemplate changes to hospital numbers though thus far he has slightly hidden behind Compton which itself did a bit of a fudge by not stating which hospitals should lose their acute status. On this issue a clear steer is required from ministerial level.

Almost everyone within health knows what needs to happen but petty rivalries, ensuring one’s own position and systemic inertia all hamper the needed changes. Poots will hopefully be willing to drive through all the needed changes and to be fair to him one of his first actions was to reduce Lagan Valley’s A+E opening hours (in his own constituency).

It has also been suggested at a very senior level within the health trusts that the current health minister has made a decent beginning and should stay in post after the rerunning of d’Hondt and for the whole of this Stormont term as the time frame for these changes is years and not weeks or months. A clear indication of this from Peter Robinson would be highly useful.

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