Matter for discussion, submitted by the RCN Dorset Branch
That this meeting of Congress discusses whether Emergency Departments should be able to say no.
Every year the ‘winter crisis’ in emergency care gets worse and every year - in some shape or form - the issue is discussed at Congress. The NHS is facing record demand and unprecedented pressure despite the outstanding effort, professionalism and commitment of frontline staff. It appears that there may never be adequate, so perhaps a radical reorganisation is required.
Education of the general public around attendance at emergency departments (ED) has not worked, and, as ‘the lights are always on in ED’, people still just turn up. IN England, 5.34 million patients attended emergency departments between October and December 2016, 200,000 more than at the same period in 2015. 15-20% of these patients could be better treated in other parts of the Urgent Care system. Patients turn to A&E because they are unclear or unable to access alternatives as the current fragmented nature of out-of-hospital services is unable to offer patients adequate alternatives. In Wales, Campaigns such as ‘Choosing Wisely’, the roll out of the integrated 111 service and investment within primary care services, could offer alternatives to an emergency department.
However, after more than 20 years of unremitting growth in attendances, the power of the A&E brand shows no signs of weakening and we need to plan for the reality that is higher attendances and admissions.
NHS Improvement has demanded every hospital in England implements a comprehensive front-door streaming model by October 2017 to enable A&E departments to care for the most urgent patients, and the Chancellor announced a £100 million fund for A&E triage projects in England in this year’s budget.
Everyone who attends A&E has the right to expect appropriate and dignified treatment, but this treatment is often best delivered by a professional who is not an emergency medicine physician. Should emergency departments be able to say ‘no’ and, following a clinical triage, turn people away, signposting them to a more appropriate service?
This would relieve the pressure on overstretched, understaffed emergency departments, prevent ambulances queuing outside, reduce numbers of people cared for in corridors and ensure that waiting times are not breached.
But in order to achieve this, A&E departments will need to be able to access the most appropriate services for patients who could be better treated. Streaming patients with urgent care needs elsewhere needs a highly responsive service that delivers care as close to home as possible, minimising disruption and inconvenience for patients, carers and families. A one-size-fits-all approach to streaming is unlikely to work as funding streams are not in place to support implementation.
In Scotland there are significant pressures on ED departments with the four-hour standard being regularly missed. This has become a political priority, with weekly figures publicly reported. Following significant pressure over the 2016-17 festive period, the Scottish Government announced a national review of four-day public holidays, on which the RCN has a seat. But pressures at the hospital front door are an indication of stresses across the entire system. For example, Scottish district nursing vacancies are at 4.2% and GPs at 4.8%, impacting on how well community services can help avoid of ED attendance. Hospital consultant vacancies are at 6.8% and over 44,000 days were lost to delays in hospital discharge in January alone, impacting on the flow of people out of emergency departments. Scotland’s Six Essential Actions on Unscheduled Care acknowledges the whole system impact on EDs and includes guidance on capacity management focused on improved flow.
Local areas need to identify the main services required and design them around patient needs. These services may include primary care, ambulatory emergency care, out-patient referral, transfer to an assessment unit and transfer to a frailty service. A well-designed streaming service supported by the availability of each of the streams during periods of high demand can reduce crowding and pressure on A&E staff leading to an improved patient experience. In this way, A&E should become a hub not a single department.
Nurses could be an integral part of the patient streaming process as we possess knowledge of the local area and specialist expertise, so we are perfectly placed to assist in redirecting patients to where their care needs can best be met by the right person, in the right place, at the right time.
“Should emergency departments being able to say no to patients walking through their doors?” Kathy Moore asked Congress. “Two years ago I stood at Congress and spoke about the crisis in emergency departments and it hasn’t improved, year-on-year the crisis worsens” she said, “The Red Cross are saying it’s a NHS humanitarian crisis”.
“Accident and emergency is a super brand that the public trust”, said Janet Youd, an emergency care nurse. She was adamant that emergency department staff should never say no, although she did recognise wholeheartedly that the problem needs looking at.
Jamie Cocksedge and others raised the problems arising out of the media reporting on inappropriate use of emergency departments. He cited an incident with an older lady who had fallen badly but who told her husband not to call an ambulance because she didn’t want to make a fuss.
The lack of health care services in rural areas was an issue raised by John Hill. He said with minor injury units and doctors surgeries being lost there were no health care facilities available to rural dwellers except for emergency departments.
Community investment and education was key to solving the problem said Roislin Devlin along with others, she spoke of people living longer with co-morbidities who use emergency departments. People need to be educated on where they can go for better options.
Chloe Stafford said nursing staff should never say no and that triage, run by qualified staff, is critical to the effective management of emergency departments.
Kathy closed the debate agreeing with Chloe and others, saying that an effective triage service would direct the right people to the right place at the right time.