Winter is always a busy time for health and social services. Building on the work done during the Fourth Assembly, the Health, Social Care and Sport Committee will be looking at the winter preparedness of health and social care services in Wales.
Terms of reference for the inquiry
In seeking assurance that the Welsh NHS is equipped to deal with pressures on unscheduled care services during the coming winter, the Committee’s inquiry will consider:
the current pressures facing unscheduled care services, and how well prepared the Welsh NHS and social services are for winter 2016/17;
whether there has been sufficient progress in the fourth Assembly in alleviating pressures on unscheduled care through integrated winter planning across health, social and ambulance services, and lessons learned; and
the actions needed to produce sustainable improvements to urgent and emergency care services, and the whole system, ensuring the Welsh NHS builds resilience to seasonal demand and to improve the position for the future.
The terms of reference include a focus on patient flow (including primary care out of hours, emergency ambulance services, emergency departments, and delayed transfers of care).
Inquiry into winter preparedness 2016/17
The Royal College of Physicians of Edinburgh is pleased to respond to the Health, Social Care and Sport Committee’s inquiry into winter preparedness 2016/17 which recognises the importance of ensuring the Welsh NHS is equipped to deal with pressures on unscheduled care services during the coming winter.
Crucially, this inquiry should also ask organisations to consider the lessons it has learned (if any) from previous years to influence future responses.
Although the inquiry is themed around ‘winter’ our Fellows and Members report that difficulties accessing unscheduled care are a key concern for staff and patients year round. Therefore ‘ensuring winter preparedness’ may feel like a misnomer when many physicians and hospitals do not ever feel they exit this period of pressure.
The inquiry notes the importance of patient flow, and each part of the unscheduled care pathway plays a part in influencing urgent and emergency care performance. Focus needs to be on what aspects of that pathway can be improved to allow flow through the Emergency Department (ED) – either back into the community, or to the correct inpatient bed, at the right time, cared for by the right person.
The Acute Medicine Unit (AMU) and acute medicine teams can play a key role in keeping the system moving, although they too report pressure throughout the year. There is not a single solution to the pressures, but there are things within AMUs that can help maintain safe care:
- AMUs run by senior clinicians and staffed by dedicated multi-professional teams
- Ambulatory emergency care with extended opening hours and senior decision makers
- Early senior review of patients to enhance care and facilitate safe, early discharge
- In-reach to ED to reduce the workload burden on Emergency Physicians
- Championing 7-day services
- ‘Discharge to assess’ ethos being used by acute therapies teams
There are poor practices, however, which should be targeted:
- Moving patients from AMUs to general or specialty wards because there are no community beds available or social care provision at home for older patients to be discharged to.
- Moving patients to non-medical beds or beds in the wrong specialty (‘boarding’) because it is the only place where there is a bed. This practice increases length of stay and has an adverse effect on morbidity and mortality. Boarding, traditionally a winter feature, is now seen year round.
- Acute admission is the final default when patients have nowhere else to turn. Many patients present to the ED with conditions that should be managed in primary care, but people can’t get in to see their GPs and community teams as they are also stretched. Having co-located Urgent Care Clinics which are adequately staffed can help with this.
- There are inadequate services for vulnerable patient groups. Not just social care provision for older and frailer patients who are medically fit for discharge, but mental health services are also stretched and physicians commonly see patients with significant mental health conditions, and no acute medical problem, being cared for in an acute hospital bed.