A&E- accident and emergency facing serious problems

Accident and Emergency (A&E) departments are facing a “serious problem” a health minister has said, after NHS chiefs ordered urgent action to tackle growing pressures.A&E- accident and emergency facing serious problemsRising attendances have meant A&E units in England have started struggling to hit the four hour waiting time target.

The problem has got so bad that NHS England has pledged extra money to help hospitals that are struggling.

But Health Minister Anna Soubry warned there would be “no quick and easy solution”.

She said: “We have a serious problem, we’ve had a problem for a while. If you look at the number of people presenting to A&E it’s grown by a million in just the last year.”

“And unfortunately unless we take urgent action, which we’ve been doing, it’s a problem which will grow. It’s very complicated. There is no quick and easy solution.”

It has been clear for some time that pressures have been growing in A&E.  For the past decade the numbers attending the units have been rising year by year. There are now more than 21 million visits annually – up 50% in a decade.

There is a combination of reasons why they have grown, including a rise in number of people with chronic conditions, such as heart disease, that end up having emergencies; the ageing population; and problems accessing out-of-hours GP care. A&E units have also had problems recruiting middle-grade doctors, which creates staffing problems.

But until recently, hospitals had just about been coping. The harsh winter seems to have tipped A&E units over the edge.

In the past few months, the waits that patients face have reached their worst levels for a long time.

The four-hour target – 95% of patients have to be seen to in this time – started to be breached in many places. Since the start of last month, the NHS overall has missed it.

There are signs that, with the weather improving so have the waiting times, but not as much as many would have liked.

The problem is that A&E is the safety net of the NHS: the place people go when there is no other option. If it breaks there is a real problem.

The situation prompted the Care Quality Commission to issue a stark warning about the future of A&E.

CQC chairman David Prior said: “Emergency admissions through accident and emergency are out of control in large parts of the country. That is totally unsustainable.”

He added: “The patient or resident is the weakest voice in the system. It is a classic market failure. The user doesn’t know nearly as much as the professionals, even with the internet.”

Soon after the CQC warning was made, NHS England announced it was asking regional health bosses to work together to ensure plans are in place for each A&E in their patch by the end of the month.

Health Minister Anna Soubry says lack of access to GP surgeries is “one of many factors” putting pressure on A&E services.

NHS could charge fees to call out a doctor

Calling out a doctor to your home could cost £8.50 under radical proposals to shore up the finances of the NHS.NHS could charge fees to call out a doctorThe proposals are being outlined as a way of tackling the financial hole in the accounts of the Health Service.

The moves sparked outrage with claims they amount to a patients’ tax and undermine the “free at point of use” principle of the NHS.

There are also fears that ill patients will be discouraged from seeking treatment.

The NHS Confederation, which represents all Health Service trusts, outlined the proposals as a way of generating extra funds and as one option in dealing with the hole in the NHS budget.

The group gave an example of a pilot scheme in Germany where 10 euros was charged for a call out by a doctor.

The federation said there was no plans to suggest charging but frank discussions were needed.

The chief executive Mike Farrar said: “We need to talk openly and honestly about why our Health Service needs to change.  We cannot risk the wheels coming off and patient care suffering.”

The report claims the radical proposals may be needed as the NHS faces soaring costs of caring for an ageing population and increasing levels of obesity.

Katherine Murphy, chief executive of the Patients Association, said the proposals undermine a fundamental tenet of the NHS.

“Some of these proposals amount to what would effectively be a “patients’ tax”, she said.  “It would be absolutely unacceptable for patients to foot bill for reform through new charges.”

Surveys have found 27 per cent of patients would delay calling out a doctor and 18 per cent would avoid it altogether if they had to pay.

However, some trusts are already considering imposing a £10-a-day fee to watch TV.

Last year, an NHS trust went into administration for the first time and officials estimate there are around 20 more in severe crisis, with combined debts of about £130 million.

The costs of propping up Private Finance Initiative (PFI) under Labour’s deal will worsen the position even more in the next decade.

Health Direct wishes you a healthy weekend as deaths rates increase by third

With the weekend approaching Health Direct wishes you a healthy weekend- as new research shows that death rates increase by a third over weekdays in NHS hospitals.Health Direct wishes you a healthy weekend as deaths rates increase by thirdMore than 3,000 people could be saved every year if weekend hospital cover and access to key medical facilities was as good as during the working week, a major analysis indicates.

Every year hundreds of thousands of people are admitted as emergencies with heart attacks, abdominal aneurysms, cancer and other conditions, and the study shows those who fall ill at weekends are significantly more likely to die.

Last year Dr Foster Intelligence, which analyses NHS data, found that on average the chance of dying in hospital following a weekend admission was 10 per cent higher than after a weekday admission.

But a new detailed breakdown by the firm shows that Patients need safe care 24 hours a day, seven days a week, for some conditions, the additional risk of dying after being taken ill at the weekend is more than triple that.

Dr Foster looked at the 12 biggest conditions where death rates for weekend admissions are higher than for weekday admissions. For each, at least 250 people die a year after being admitted at a weekend.

In total, they analysed 337,385 weekday admissions for those 12 conditions, and 100,590 weekend admissions.

Roger Taylor, director of research at Dr Foster, said: “These mortality figures are a worrying sign of the NHS’ failure to modernise its working practices.”

He said seven day working could help improved patient care and also “help NHS trusts run more efficiently”.

The research also revealed much lower access to some key medical tests at weekends.

For instance, the chance of getting a prompt emergency MRI scan at the weekend is almost half that on a weekday.

Dr Foster found the risk of dying in hospital of complications caused by thickening of the arteries, such as a heart attack, is 20 per cent for weekday emergency admissions.

For weekend emergencies, the figure rises to 28 per cent. That is an increase of eight percentage points, which translates to a relative raised risk of 40 per cent.

Patients with an abdominal aneurysm – where a major artery has burst or is about to do so – the death rate for weekday emergency admissions is 27 per cent. At the weekend that rises to 37 per cent, an absolute rise of 10 percentage points, but a relative rise of 37 per cent..

For pancreatic cancer, the weekday death rate is 25 per cent and the weekend rate 34 per cent – an eight point rise but a 36 per cent uplift in relative risk.

Large scale studies showed abdominal aneurysm patients did better if smaller units were downgraded and services centralised in larger hospitals, he said, even if that meant longer in an ambulance. The same has been shown for strokes: death rates dropped in London when services were reorganised in this way.

Lack of weekend NHS consultants risking patients’ lives

Seriously ill patients are being put at risk on NHS wards because not enough consultant doctors are working at nights or weekends.Lack of weekend NHS consultants risking patients' livesConsultants are sometimes “reluctant” to work weekends, say the authors of the report published today by the Royal College of Physicians (RCP) in New toolkit to deliver increased consultant care to acutely ill medical patients with the help of the Society for Acute Medicine.

Hospitals will need to switch more consultants from weekday to weekend rotas, say the organisations and where that is not enough they will have to employ more of the senior doctors.

Studies show the chance of dying in hospital is between 10 and 14 per cent higher if admitted as an emergency at the weekend than during the week.

The two organisations are consequently calling on hospitals nationwide to ensure that a consultant is present on every acute ward for at least 12 hours a day, seven days a week.

At most only four in 10 hospitals currently meet this “gold standard”. Frequently smaller district general hospitals which have problems filling weekend rotas, fail to do so.

Dr Chris Roseveare, president of the Society for Acute Medicine, said: “Clearly, when you go to hospital as an emergency you are vulnerable.  You need to be cared for by someone with the skills to deal with the acute problem. Consultants have those skills.  Going into a hospital where there isn’t a consultant available is something we want to avoid.”

But he said: “There’s a culture in which consultants are traditionally reluctant to provide weekend working.”

He explained: “Traditionally the consultant’s job plan has been geared around providing a weekday service, plus a weekend service shared with colleagues.”

What the Society and the RCP wanted to do was create weekend emergency care which mirrored that provided in the week, as closely as possible without damaging the weekday service.

Dr Mark Temple, an acute care fellow at the RCP, said consultant-led care was “key” to delivering the highest quality care.

Even when consultants were at hand, he said, they were often torn between their acute medical unit (AMU) duties and responsibilities elsewhere.

“They are pulled in two directions,” he said. The organisations want this “doubling up” to stop.

Consultants should also start by 8am so they can do their ward rounds and give patients admitted overnight a full and prompt assessment, the report recommends.

Last week the RCP warned that the “erosion” of the ward round meant that some doctors were not giving patients the time by the bedside they needed to properly gauge their needs, recognise them as people rather than ‘conditions’, and share vital information with nurses.

Patients’ lives at risk in NHS hospital wards on brink of collapse claim Doctors

Patients’ lives are at risk in NHS hospital wards that are “on the brink of collapse” due to a critical shortage of out of hours doctors and growing numbers of the elderly.Patients' lives at risk in NHS hospital wards on brink of collapse claim DoctorsSome hospitals narrowly avoid a “catastrophe” every weekend, research by the Royal College of Physicians has found, because doctors’ shifts are limited by the European Working Time Directive and they do not want to work anti social hours.

Some are “struggling to cope” with the volume of older patients. Many are discharged in the middle of the night or shunted around “like parcels” to free beds for new arrivals.

If the problem is not tackled there will be more tragedies like the Mid Staffs scandal, in which up to 1,200 mainly elderly patients died from substandard care. A radical reorganisation of the NHS is needed, according to the college. It may include shutting the worst-performing hospitals to expand care at better ones, with more staff coverage at nights and weekends.

The Hospitals on the Edge report warns that:

  • Four in 10 doctors surveyed said that staff shortages were jeopardising patient care
  • One in four was concerned about the impact of the Working Time Directive, with one warning that “weekends and bank holidays function on a skeleton staff of doctors – very dangerous”
  • Doctors are reluctant to work unsociable hours, leaving one in 10 consultant posts in emergency medicine vacant
  • Over-65s account for seven in 10 beds, but the “the system continues to treat older patients as a surprise, at best, or unwelcome, at worst”.

The report notes that the number of beds in acute and general wards has fallen by a third over the past 25 years, while patients have increased. Beds have been cut as better care has led to shorter stays.

Dr Andrew Goddard, medical director for the college’s workforce unit, said: “Many hospitals run a traffic light system for their status: they are green if they are taking in patients; amber if they need to be a bit more careful; red for full or black if they are shut.

“What we’ve seen over the past year or so is that a number of hospitals are on red alert or black alert. A black alert used to be a once-in-a-lifetime thing. Now hospitals are on black alert three or four times a year.

“This has been coming on for a while. The system can’t cope much longer, and we need to radically rethink how we provide the care for acute medical patients, particularly the elderly.”

Prof Tim Evans, of the college’s future hospital commission, said that the eurocrats’ Working Time Directive, which limits doctors to a 48-hour week, was a “huge issue”.

Many doctors have complained that it has led to gaps in rotas, compromising patient safety, and prevented juniors from acquiring necessary experience.

He said that employment contracts for junior doctors reduced flexibility on working hours and needed to be renegotiated. Prof Evans said: “That leads to fragmented care and tragically to a lack of compassionate care, with staff rushing between patients, firefighting. Acute wards are on the brink of collapse.”

He warned: “There will not be some cataclysmic overnight explosion but there will be a gradual increase in the sorts of tragedies that we’ve heard about at Mid Staffs.”

Sir Richard Thompson, president of the college, said: “One doctor told me that his trust does not function well at night or at the weekend and he is ‘relieved’ that nothing catastrophic has happened when he arrives at work on Monday morning. This is no way to run a health service.”

Suzie Hughes, chairman of its patient and carer network, said that during a recent hospital stay she underwent five ward changes “all of which took place after midnight”.

She added: “All routine blood tests were done at approximately 3am as the junior doctors only had time to do them then. It is clearly unacceptable.”

Patients swamp A&E as GPs cut surgery hours

Hospital Accident and Emergency departments are being swamped by patients who cannot visit GP surgeries or NHS walk-in centres, leading to longer waiting times.Patients swamp A&E as GPs cut surgery hoursThe reduction in opening hours is forcing some patients to wait up to three weeks for a GP’s appointment.

Information provided by almost two thirds of NHS primary care trusts indicated that almost 500 surgeries in England have stopped offering evening and weekend appointments.

Andy Burnham, the shadow health secretary, who commissioned the research, raised concerns that the NHS was being turned into an organisation that works for the convenience of doctors, rather than patients.

In April 2010, David Cameron promised that the Conservatives would ensure that GP surgeries remained open “until 8pm, seven days a week”.

The Coalition has abolished the official survey of GPs’ opening hours and is giving more power to doctors to commission and organise health services for patients in their areas.

However, figures from 91 primary care trusts, obtained by Labour under the Freedom of Information Act, showed a fall in the number of surgeries offering extended opening hours in half of NHS trusts.

Nationally, the survey suggested there had been a 5.7 per cent decline in surgeries offering weekend and evening appointments. This would be equivalent to 477 surgeries serving more than two million patients across England.

Labour said 26 emergency care units, including 12 NHS walk-in centres, had closed in the last year. At the same time, hospital emergency departments have been overwhelmed by one million more patients this year than in 2011, the Opposition claimed.

Mr Burnham said: “People are turning up at accident and emergency sicker and you get fewer staff to deal with them. David Cameron made a lot of promises on the NHS and one by one we are seeing them broken. The combination of the financial challenge with the biggest ever reorganisation of the NHS has served to severely destabilise the NHS.”

Mr Burnham said that more than 1,300 patients had contacted the party with concerns, many reporting that it takes two to three weeks to secure a doctor’s appointment. The worst affected area for cuts to opening hours was Hartlepool, where 31 per cent of surgeries were operating a reduced service. In Newcastle and Haringey, a quarter of practices were reducing opening hours.

The research also found that accident and emergency wards in 46 NHS trusts were not meeting the maximum waiting time of four hours.

A Conservative party spokesman said it was “more than a bit rich” for the Labour to complain about doctors’ opening hours “when it was their disastrous GP contract which meant that 90% of surgeries stopped offering this service altogether”.

“Our plans to put doctors back in charge of the NHS, which were opposed by Labour, will mean that local doctors will once again be responsible for caring for their patients out of hours and will offer patients a real choice of which GP surgery to go to,” he said.

From:  http://www.telegraph.co.uk/Patients-flood-AandE-as-GPs-cut-surgery-hours

Doctors fear catastrophes on hospital wards at weekends

One in eight doctors does not think hospitals provide high quality care at weekends and “catastrophes” are feared on wards because staff cover is so poor.Doctors fear catastrophes on hospital wards at weekendsA survey of senior doctors has found that many are concerned about the care patients receive at weekends, when most hospitals only have a skeleton staff.

One respondent to the Royal College of Physicians poll said: “I often feel relieved on Monday that nothing catastrophic has happened over the weekend.”

Sir Bruce Keogh, medical director of the NHS, has told The Daily Telegraph that hospitals should look no different on a Saturday to the way the look on a Wednesday.

He wants the NHS to offer a full seven day service with routine appointments and operations carried out at weekends instead of emergencies only.

At a meeting at the Royal College, Prof Tim Evans, academic vice-president, reported on progress that the college had made with its Future Hospital Commission, which is investigating how to improve care. He said hospitals were under substantial stress and were providing a disjointed service to patients with a lack of compassion and continuity of care.

The Royal College survey found that hospital doctors were concerned that patients saw a succession of medics and had to repeat their problems each time.

More than one in eight said they rated their hospital’s ability to provide high-quality care seven days a week, as poor or very poor.

Prof Evans said: “I’d rather have a hospital working at 80 per cent of its best seven days a week than one that is 100 per cent five days and only 20 per cent at weekends.” The commission, chaired by Sir Michael Rawlins, aims to come up with ideas to ensure hospitals can cope with the increasing complexity of cases, an ageing population and changes to doctors’ working patterns.

Almost 7,000 doctors responded to the survey. Other studies have disclosed concerns from junior doctors who feel out of their depth at having to look after patients outside their areas of expertise when covering wards at weekends and at night.

The General Medical Council has warned that hospitals may be facing significant problems because juniors were being asked to cope with issues beyond their competence.

From: http://www.telegraph.co.uk/Doctors-fear-catastrophes-on-hospital-wards-at-weekends

Number of overnight discharges from NHS hospitals to free beds row

An investigation has started after figures emerged suggesting that a number of NHS hospital patients in England have been discharged overnight to free up beds.Number of overnight discharges from NHS hospitals to free beds rowThe Times newspaper discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 23:00 and 06:00.

NHS medical director Prof Sir Bruce Keogh said people should be sent home only when it was appropriate and safe.

The paper had contacted 170 NHS trusts in England but only 100 responded.

However, the rates of those discharged varied widely between different hospitals.

The paper reported that some 3.5% of all hospital discharges took place between those hours and this rate had steadily held for the past five years.

On the face of it, it seems shocking that any patients are being discharged at night. The data obtained by The Times suggests this may be happening in 3.5% of cases.

But that needs putting into context. It seems some hospitals are including patients who have died in their figures, while some patients, such as women who have had a baby, may choose to leave at night.

Nonetheless, it is clear there are also many cases of inappropriate discharges.

This reflects the pressure hospitals are under. Admissions to A&E units have been rising for years – and if more people are coming in, more have to leave.

The problem is compounded by the fact hospitals have very little wriggle room. They are supposed to operate at only 85% capacity, but all too often they are closer to 100%.

It means when there is a surge in patients, there is no leeway in the system – and something has to give.

If the remaining 70 trusts discharged their patients at similar rates, this would add up to 400,000 such discharges a year and almost 8,000 a week, the paper added.

Derby Hospitals Foundation Trust sent 8.7% of its patients home overnight but the trust told the Times there may have been a problem with its records.

Others with rates above 7% include the Heart of England NHS Foundation Trust in Birmingham and Countess of Chester and University Hospitals of Leicester trusts.

Newcastle Hospitals Foundation Trust and Southend University Hospital Foundation Trust both said they did not discharge patients during the night.

The Times does state that the data is variable and while some hospitals admitted to keeping detailed records, others said they could not guarantee the accuracy of the figures as details were not necessarily recorded accurately.

The paper also adds that some hospitals categorise deaths as “discharges” while others do not.

Patients more likely to die if admitted to hospital at weekends

Research finds that patients are more likely to die if they are admitted to hospital at the weekend.Patients more likely to die if admitted to hospital at weekendsThe study Weekend hospitalization and additional risk of death: An analysis of inpatient data was published in the Journal of the Royal Society of Medicine, found that patients were 16% more likely to die if they were admitted on a Sunday than mid-week.

The review looked at all admissions to NHS hospitals in England in one year.

The NHS medical director has called for weekend services to be extended.

The research was carried out at University College London and the universities of Birmingham and East Anglia, and covered more than 14 million hospital admissions – both emergency and planned.

The study looked at more than 187,300 patients who died within 30 days of being admitted to hospital during 2009-10.

The researchers found higher death rates if patients went in at the weekend, but a slightly lower death rate if people were already in hospital at the weekend.

For every 100 deaths following admissions on a Wednesday, 116 occurred for admissions on a Sunday – a “significant increased risk”, the researchers said.

These results confirm previous reports of increased 30-day mortality risk for patients admitted to hospital with emergency conditions at the weekend”

Prof Domenico Pagano University Hospital Birmingham Foundation Trust

They added: “We identified a significantly higher risk of subsequent in-hospital death during the 30-day follow-up period associated with admission during the weekend (Saturday or Sunday), compared to mid-week days.

“Admission on Tuesday through Friday was associated with the lowest risk of in-hospital death, while admission on Sunday was associated with the highest risk.

“Admission on Saturday was associated with a marked increased mortality (death) risk and admission on Monday was associated with a less, but statistically significant, increased risk.”

Researchers said the results were consistent with data from 254 not-for-profit hospitals in the United States, which they also analysed.

Lead researcher Professor Domenico Pagano, from the University Hospital Birmingham Foundation Trust, said the results offered conclusive evidence.

Prof Pagano also said reduced staffing and fewer senior doctors on duty, as well as poor access to diagnostic tests at weekends, could have an effect.

His team said seven-day access to “all aspects of care” could improve the outcomes for higher-risk patients currently admitted at weekends.

The medical conditions resulting in the biggest number of in-hospital deaths included pneumonia, congestive heart failure, heart attack, septicaemia, acute renal failure, urinary tract infection and neck or hip fracture.

“We’ve tried to take account of the severity of illness and we’re not clear yet whether it’s the severity of illness or the way we deliver services that are the key thing.”

He also said he thought the research added weight to the argument to extend NHS services through the weekend.

“It’s about our NHS catching up with other service industries and offering a routine six- or seven-day week where people can see consultants or experts on a Saturday and maybe even a Sunday, where people can have routine operations over the weekend – more at their convenience than the convenience of the service – and also people who are worried on a Friday have access to expert advice – and that’ll put the compassion back into the NHS.”

Patients at risk as health trusts cut out of hours care

One in four NHS trusts has cut spending on out of hours care, new figures disclose.
Patients at risk as health trusts cut out of hours careAt least 20 trusts have reduced their budgets for doctors to visit patients in the evenings and at weekends by a total of £4million.

The cuts in after-hours budgets led to warnings of a repeat of the case of Daniel Ubani, the incompetent German locum who killed a Cambridgeshire man with a morphine overdose in 2008.

About 78 of England’s 152 primary care trusts released information on their out-of-hours spending after Freedom of Information Act requests by the magazine GP. Twenty said they had cut their budgets.

The cuts, made in the trusts’ 2010-11 budgets, come before the start of the next four-year spending round, which will require the NHS to find efficiency savings worth £20 billion.

Across the remaining trusts that released information, total spending on out of hours care rose by only £3.6 million.

Health experts said some trusts might have been able to make savings without affecting services, by renegotiating inflated contracts.

However, doctors and patients’ groups said that in many cases lower spending would add to concern about the quality of care.

A study commissioned by the Department of Health last year found wide variations in the quality of care provided by out-of-hours contractors, including GP groups and private health care firms.

Katherine Murphy, the chief executive of the Patients’ Association, said the latest cuts would reduce the quality of care, risking “a repeat of the case of Dr Ubani”.

She said: “By pressuring providers to look for ever cheaper options, the Government is forcing them to enter a race to the bottom.

“Out-of-hours services need to be staffed by doctors who are as trained and experienced as their colleagues who work during the day. Cutting funds to pay for them will mean fewer and possibly less able doctors.”

Dr Fay Wilson, who chairs an out-of-hours group in Birmingham, said cutting out-of-hours care was a “false economy” for trusts because more patients would be forced to seek care from accident and emergency wards.

“If you are going to reduce the cost, then you will be reducing the number of clinicians you have on,” she said. “That leaves gaps. You also don’t get the same level of supervision and support.”

Richard Vautrey, of the British Medical Association, said cutting costs could harm services.

“There is a concern that you can pare a service down to such a level and reduce funding to such a level that you put patient safety issues at a higher risk,” he said.

The Department of Health said the Coalition was improving out-of-hours care. A spokesman said: “This is not about cutting costs – we are investing an extra £10.7 billion in the NHS – it’s about ensuring GPs, not bureaucrats, are responsible for securing safe and appropriate out-of-hours care.”

The BMA also published a poll which it said showed that most GPs opposed government plans to give them control over £80 billion of NHS budgets.

About 65 per cent of family doctors believe competition between providers, including NHS and private companies, will reduce the quality of patient care, while 61 per cent said the Government’s reforms mean they will spend less time with patients.

The Department of Health said the survey showed some doctors had “misconceptions” of the planned reforms. Andrew Lansley, the Health Secretary, said there was no alternative to his reforms to make the health service more efficient.

“Unless we modernise, every year the relative costs of running the NHS will go up,” he said. “Demand will grow, the bureaucracy will expand and inefficiencies will become entrenched.

“There is no easy option. Sticking with the status quo and hoping that a bit more money will be enough to meet the challenges ahead is a complete fiction.”

From: http://www.telegraph.co.uk/Patients-at-risk-as-health-trusts-trim-out-of-hours-care