While media stories often refer to meeting the four-hour A&E standard as a measure of success, this key standard is more of a bell-weather for the strength of a local health and social care system than it is a measure of the ability of individual acute trusts and on his recent Newsnight interview, Jeremy Hunt said that it should not be the only measure used to assess the success of emergency care.
Most NHS leaders would agree with this, but it is not how it feels to those running local systems when they are with their staff in the A&E department at 4am in the morning. It is also not how it feels when you are apologising to patients and relatives for the lengthy waits or the experience they have had in departments treating many more patients than they were designed for or where there are far fewer staff than there should be. It definitely isn’t how it feels when you are in a performance conversation with the regulators.
As a past chief executive, who has worked in some of the most challenged systems for emergency access, I have felt all this and much more besides. And while winter exacerbates the situation, long gone are the days when pressures on emergency services lasted only from December to the end of February. Spikes in demand, staff shortages, increased patient acuity, and capacity pressures in primary, community and social care remain pretty consistent throughout the year and pressures on performance continue largely unabated.
To staff this means it feels like black alerts are often the order of the day and the effectiveness of such escalations reduces as they become normalised. A black alert is effectively the highest level of escalation for local health and care systems and means that there is more demand than capacity with very large numbers of patients in A&E, no capacity in the medical assessment unit (or equivalent), ambulance handovers and numbers of patients waiting for beds in A&E increasing significantly with no immediate resolution that will get the system back into a positive position. It is an unacceptable position for clinical staff, managers and of course patients.
When a black alert is called (in my experience most frontline staff don’t use or understand the new ‘OPEL’ national reporting system for hospital pressures, which appears to them to be much more about managing upwards to regulators than it does helping on the ground) the internal hospital meetings to manage and plan the use of beds become more regular, more difficult and more tense. There are also wider system calls made to garner and co-ordinate support from others including input from the provider of the out-of-hours GP service, NHS 111, care homes and the voluntary sector. There is much discussion and sharing of the current position but often these wider system calls add more complexity and reporting requirements than actual help to manage the situation on the ground at the time.
Staff in the hospital and partners in the local health and care system rally round and make extra efforts to increase discharges, get more staff into A&E, work with the community and ambulance trust to manage and reduce pressures as well as decide on whether to cancel elective surgery or outpatient appointments to free up staff time and physical space. Some of this effort does deliver results, but the effort is huge for the scale of difference it makes and the same job is required of the same people the next day so they get increasingly tired and stretched. In reality, and as acknowledged by the Prime Minister and Secretary of State, staff from across the system consistently work exceptionally hard in ever more difficult circumstances but it feels as if people are working ever harder just to keep services safe rather than focusing on improvement, transformation or consistently achieving the four-hour A&E standard.
However, while action is taken to manage the challenges of excess demand in the moment, the additional effort from staff and bed capacity that can be accessed during a time of crisis, in my experience, is limited and not sustainable. Every day staff and local systems are already working at or above capacity and so, for the foreseeable future, when demand rises black alerts will be called and staff from across the system will continue to do their absolute best to maintain as safe and as timely a service as possible.
The NHS front line is highly skilled and experienced at managing in a crisis or, as some would say, managing the challenges that are occurring despite the best planning for winter pressures. However, expecting staff and local systems to work in this way in the long term is no way to run high-quality services for patients or create a positive working environment for staff at all levels. If black alerts are only to be used when something out of the ordinary happens and an immediate emergency response is needed and not just become a daily occurrence, things need to change.
What we need are new, more integrated ways of working across health and social care to change how the whole system works. Evidence from some of the accountable care pilot sites is showing that can be done in emergency care but we also need longer-term planning, the appropriate level of resources, support to frontline staff and leaders who need to be given space and time to innovate and transform longstanding problems while not fearing for their jobs. Without this the gap between plans, the rhetoric and the reality of the current situation will widen so the health and care systems must work to change this for the benefit of patients, the public and NHS staff.