Seven ways to stop the NHS bursting at the seams

10:01 am - July 28th 2013

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by Dr Richard Taylor
Our A&E departments are bursting at the seams. Every week there are more reports of increasing waiting times and unsafe patient care.

Aside from the glaringly obvious need to suspend the closure of 35 A&E departments across the country, there are other urgent steps the government must take.
1.      Improve out-of-hours GP services. This can be done and my local example of this in Shropshire proves it. “Shropdoc”, the Shropshire Doctors Co-operative Ltd, provides urgent medical services for patients when their own surgery is closed and whose needs cannot safely wait until the surgery is next open  Their website states: “If you need urgent medical attention that will not wait until your own surgery is next open, call 08444 06 88 88.

If your condition cannot wait for 1½ hours this is likely to be an emergency please dial 999 Eg: Choking, Chest Pain, Blacking out, Blood loss.” Shropdoc is a member of the Federation of Social Enterprise Health Care Providers (Urgent Health UK) which covers about 17 other areas in England with wide, patient satisfaction. Unfortunately the Health Secretary Jeremy Hunt does not appear to be supportive of this eminently sensible way of bringing suitably qualified GPs back into providing out-of-hours urgent care.

2.   Stop the reductions in hospital beds until services outside hospitals are available for those that can be cared for in the community. A shortage of beds in a hospital compounds the problems in A&E because patients cannot be moved to a ward quickly enough.

3.      Speed up the discharge process of inpatients to free up hospital beds more quickly.

4.      Friday and Saturday night problems in A&E departments, and for ambulance services, are compounded by alcoholics and particularly young binge drinkers. Setting a minimum price for alcohol would alleviate this.

5.     Revamp the 111 helpline. The now infamous 111 number was introduced with two aims. Firstly, to direct patients not needing to call 999 to appropriate care for their urgent illness or injury. Secondly, to avoid unnecessary attendances at A&E departments. With appropriate triage systems and phone lines run by medically qualified staff and set up on a national, un-privatised basis, this number could still work excellently for both purposes.

6.      Establish multi-agency response teams. Ensure that all areas of the country have teams of health professionals available to patients and GPs to assess patients, particularly the elderly, who are apparently in need of hospital admission, to direct them to more appropriate local health care to keep them out of the A&E department and the hospital unless absolutely necessary. In some areas these exist and have been called multi-agency response teams.

7.      Integrate minor injuries units with A&E departments.  Ensure much better integration of minor injuries units (MIUs) with their parent A&E department by, for example, rotating shared staff so that MIUs are enabled to cope with more emergencies and all staff members are aware of this. At a recent visit to my local A&E department, over-hearing nurses talk, it was clear they did not know which local MIUs were open 24 hours per day.
Should we pay emergency care doctors more? Yes and no. Working with medical and surgical emergencies should be a very exciting and attractive part of any young doctor’s training leading to adequate numbers choosing these fields for their careers.

Pay increases would make little difference to the right sort of doctor.

However, in the short term, until working in casualty departments becomes an attractive proposition again, the only way to improve levels of staffing may be to pay more to appropriately qualified doctors. This could be offset by reducing the huge amounts currently paid to agency locum doctors, sometimes of inadequate experience and training.

Dr Richard Taylor is co-leader of the National Health Action Party and former MP for Kidderminster & ex-member of the Health Select Committee. The National Health Action Party was launched at the end of last year by doctors and health care workers seriously concerned about the impact of the government’s NHS reforms.

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Reader comments

1. Baton Rouge

The biggest improvement to the NHS would be worker-elected management. Replace the political patronage that currently selects NHS leaders and managers constantly plotting the best way to privatise the service and imposing endless reorganisation above the heads of the people that count with managers elected by the workforce having explained how they intend to make the service work for the staff, the patients and within its wider democratic remit.

In the meantime workers of all grades should be established to challenge for management of the hospital, trust, NHS and can argue for continued social ownership and the reversal of all privatisations. The trades unions, far from seeing this as a threat should throw their weight behind it.

I agree with most of what you say here particularly the out of hours service, locum pay, and preventing the closure of many A+E departments. However you have not touched on the fragmenation and chaos caused by the current reforms which are impacting on services along with the efficiency savings, resulting in a shortage of staff which was a key factor highlighted in the Keogh report. I agree with Baton Rouge that we need a reversal of privastisation and more decision making being given to the workforce so there is a collective ownership from the bottom up not the top down, which David Cameron said there would not be, but then again he said the NHS would not be privatised and that it was safe in his hands, yet we have a health secretary who co-authored a book stating it was a 60 year mistake!

Are you sure the pressure to discharge inpatients quickly is not already too great? I know of two people who had to be returned urgently, one hemorrhaging dangerously.

Is it still the case that, once the patient leaves the hospital, the case is closed, so there are no statistics for how often it occurs.

4. the a&e charge nurse

For this interested in number crunching here is some data on patterns of A&E attendance over the last 25 years

[1] ‘Improve out-of-hours GP services’ – I don’t think GPs would be very keen to take back responsibility for 24/7 care – ‘out of hours services’ have a rather patchy record and could only deal with a modest proportion of the numbers we are taking about here.

[2] ‘Stop the reductions in hospital beds until services outside hospitals are available for those that can be cared for in the community’ – the relentless downsizing of beds will continue to be driven by the economic climate in health care (see capacity in PFIs) – the provision of adequate community services to meet the shortfall is pure fantasy.

[3] ‘Speed up the discharge process of inpatients to free up hospital beds more quickly’ – this has been done to death already, most emergency admissions can expect the bed to be warm from the last patient who was in it.

[4] ‘Setting a minimum price for alcohol would alleviate this’ – you simply can’t set policies like this on weekend A&E attendances.

[5] ‘Revamp the 111 helpline’ – preferably by scrapping it.

[6] keep them out of the A&E department and the hospital unless absolutely necessary (via multi-agency response teams) – this sort of response would be great but relies on an integrated system with capacity in the community – it may work in some places.

[7] ‘Integrate minor injuries units with A&E departments’ – this is like moving the deck chairs on the titanic – MIUs should be fit for purpose – digital radiology enables an opinion from anywhere in the NHS.

5. citizen689

1- Would patients have to pay for this service? No detail. Social enterprises do not run by themselves.
2- My experience as a patient using 111 is that it was exactly the same process as with the former NHS Direct number. Same questions, approach and triage.

No mention of making better use of what is already there. Rolling weeks, better scheduling of operations, do not include time in hospital but not working as working time for working time directive. The first two have already been tried and reported on,both positively.

There is quite probably a lot of scope for efficiency savings from the bottom up, using ISO 9000 methodology, but the main thing the health service needs is to attract the best managers and trust them to get on with the job. Collecting taxes properly and closing loopholes that allow megacorps to rob us blind to pay for the service is important too.

8. Carol MIlls

Some good ideas. But regarding point 3 we have to be careful. Patients can fall down the gaps between health & social care, & that is being massively cut too. I highly recommend Scriptonite’s recent brilliant article:

9. Charlieman

@7. Cherub: “There is quite probably a lot of scope for efficiency savings from the bottom up, using ISO 9000 methodology…”

Undoubtedly, the NHS has to change, but processes such as ISO 9000 or ITIL contributed to the pickle that it is in. To go forward, go somewhere else.

What are models for co-operative working other than the Co-op and John Lewis, especially models outside retail?

Baxi gives a few clues:

Have a look also at Upside Down Management:

As a retired A&E nurse with several years experience of working nights, I think your suggestions are sensible and sound.I would add one other suggestion which is, I think, crucial to all departments. Its essential that staffing levels are maintained at adequate numbers with the right skill mix at all times. Its equally important that staff are employed on proper contracts (NOT zero hours) and paid decent wages with a return to extra duty payments for weekends, nights and bank holidays. Whilst I agree that pay is not the prime motivator in a job like A&E nursing, I do think people should be properly rewarded for hard work, in order to keep morale up. I loved the job and got huge satisfaction from it – even the nights when I never had time for a brew let alone a meal break! I simply can’t understand why Hunt is resisting the idea of compulsory staffing levels. Its a no brainer.

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