Feeling the NHS pressure

A week after Scarborough Hospital declared a major incident due to the unexpectedly high demand for its services, Chris Bond visited the A & E department.

Mike Procter, deputy chief executive, in Scarborough Hospital Emergency Department.

IT’S 10.55 in the morning and the Accident and Emergency department at Scarborough Hospital is hotting up.

Most of the 11 A&E cubicles are occupied and a flurry of doctors and nurses are hard at work. Many of the patients here at the moment are elderly. One man is on a bed and requires an oxygen mask, while across the aisle a woman is being treated for what appears to be a knee injury following a fall.

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It’s busy, but Mike Proctor, deputy chief executive at York Teaching Hospital NHS Foundation Trust, says it’s not as busy as it was on Monday last week.

“Patients were queuing all along the corridors,” he says. Some people had to wait 12 hours to be treated and with no spare beds at nearby hospitals to help ease the pressure Proctor took the decision to call a ‘major incident’ as the hospital had reached its capacity.

A major incident is a sign that things have got exceptionally busy and special measures are needed to cope, which can happen in winter when demands are high. The problems at Scarborough came after two hospitals in Gloucestershire also declared major incidents owing to high demand in their A&E departments. This followed a warning from Sir Bruce Keogh, the medical director of NHS England, who said in November that A&E units were “creaking” under the pressure.

Proctor says that one of the challenges for Scarborough’s hospital 
is that it’s quite small – it has around 220 beds, compared to York Hospital which has 750. “If you’re a small hospital then an increase of 10 or 15 patients in a day can make a massive difference.”

The first working Monday of the new year is traditionally a busy time for hospitals with GP surgeries and other services having been scaled down over the festive period, but last Monday was particularly bad.

“When I got here every bed was already taken so we had no spare beds for new admissions,” says Proctor. “I’ve been an operations manager for 17 years and I’ve never seen anything like it. I’ve never worried before that an emergency department might cease to function properly and I did on Monday.”

Sometimes when services are stretched paramedics are told to divert patients to other hospitals, but in this instance those in Hull and York were full. “I knew we couldn’t rely on anyone else so I took the decision to call a ‘major incident’.”

The hospital was forced to postpone some planned surgery and other procedures as staff were pulled in from other areas and off-duty doctors and nurses helped muck in. It’s the first time there’s been a ‘major incident’ called at Scarborough Hospital for this reason, and it’s not a decision taken lightly. “It’s not like you’re ringing them up and asking if they would like to do another shift, staff know that it’s serious.”

Proctor is fulsome in his praise of the doctors and nurses who gave up their time. “It invoked something of a ‘Dunkirk spirit’ and this idea that we’re all in this together and I have to say the staff were fantastic.”

By getting more doctors to help out on the ward they were able to discharge people quicker and make some more beds available the next day at Bridlington Hospital and Malton Hospital, giving them the breathing space they needed.

After 24 hours the “major incident” call was stood down, but it’s a situation he doesn’t want to find himself in again. “I don’t want to be calling any more because it wouldn’t have the same impact, unless it’s three years down the road. But we may have to, I really don’t know.”

There are a number of reasons why A&E departments up and down the country are struggling to cope with the growing pressure. Part of the problem is encouraging enough young doctors and nurses to opt to work there in the first place.

“The thing with emergency medicine is it’s such a high pressure speciality,” says Proctor. “The hours are anti-social and there are other more attractive, often better paid, alternatives. As a result, emergency medicine is not a popular specialism to go into at the moment.”

One of the fallouts from the Mid Staffordshire NHS Trust scandal – which saw a public inquiry triggered at Stafford Hospital after a higher than expected number of deaths at the trust – was that it forced health trusts to focus on staffing levels, with many hospital bosses, including those at Scarborough, deciding they needed more nurses.

Proctor says they tried to recruit more staff last summer to help cope with the anticipated winter demand but got little or no response. “Scarborough has more than 30 qualified nurse vacancies, which is more than a ward’s worth, and we have struggled to fill them.”

Which is why they are now looking to Europe. “We’re going to Spain next month to recruit nurses that are unemployed who are coming off a training scheme there but can’t get a job. We want to bring 40 to Scarborough and that should make a huge difference in terms of our capacity – so there is light at the end of the tunnel.”

The lack of homegrown nurses dates back three years when health planners under-estimated the numbers needed. However, Proctor would like to see nursing less tied to academic qualifications.

“My personal view is there’s too much emphasis on 18 year-olds with three good A-level results and I think that’s a mistake. I think we should lower the requirement in academic terms because we need the right type of people and some more mature people might not have three A-levels, but actually they’d make excellent nurses.”

Another issue that impacts on A&E wards is the fact that people are living longer which, ironically, is due in part to the success of the NHS over the years. Average life expectancy in this country has gone up by 12 years since 1948, but our ageing population is putting burgeoning demands on our health service. “If you’re 85 and you’re ill, it’s going to take you a lot longer to recover than someone who is 60 with the same condition. You’re ill for longer and it takes more time to get over it.”

Procter says the A&E system needs to change if it is to be sustainable in the long run. “We have to develop better community services in order to support patients either in their homes, or closer to where they live, using community hospitals and day care, which we’re already doing through pilot projects in Malton and Selby.”

He also believes that health and social care need to become more integrated.

But Proctor, himself a qualified nurse with 30 years’ experience, says one thing is certain: The current structure needs to change. “The answer can’t be to keep putting more and more beds in the system because we haven’t got anywhere to put them and it’s really expensive.”