Winter pressures and emergency care: a view from A&E

This transcript was auto-generated and may contain small errors.

As the year draws to a close, many will be looking forward to the festive season.

But with winter approaching, increased sickness in patients and staff often leads to overwhelmed and overcrowded health services.

For the NHS and social care sector, winter is never easy.

Hello and welcome to The King's Fund podcast, where we explore the big issues and ideas in health and care.

I'm your host, Ruth Robertson, and today we will be exploring what it feels like to work at the front line of urgent and emergency care during winter.

I'm delighted to be joined by two guests, Kelly Ameneshoa, an emergency doctor and previous population health fellow at The King's Fund, and Charlotte Wickens, policy advisor here at The King's Fund.

Kelly, Charlotte, welcome to the podcast.

Thanks for having us, Ruth.

Yeah, hello, thanks for having us.

I read a lot about winter pressures from a health policy perspective, like data on overcrowded services and last minute injections of cash, but I really want to understand what it's like working in the health system over winter.

So Kelly, can I begin by asking you to tell us a bit about your job and what it's like working in the health sector during winter?

Sure.

So I'm an A&E registrar doctor.

So that means I'm fairly senior within my A&E training.

I've got about a year left until I'll be a consultant.

And we move across different hospitals in different regions as part of our training.

Winter is always a time that's sort of dread coming up to, especially from an A&E perspective.

As the years have gone on in my training, the difference between winter and summer is not as great.

And certainly that's because summer is catching up with the winter rather than winter is getting better.

And that just means there's even more pressure as the winter comes because you're already starting from quite a difficult position.

So for example, the hospital I'm at at the moment, already in the summer, we're using the corridor space for patients.

When you're already piling up trolleys in the corridor and delaying ambulance handovers, and then you know that winter is only going to get worse, you do get this ominous feeling of how are we going to manage, how are we going to try and give good patient care when we know that we're stretched before we even start.

I'm so struck by you saying that you start to feel this dread as it comes towards winter.

And I just wondered, as you think about winter pressures, are there any kind of stories or examples that come to your mind from your own work that really illustrate what it's like and what those pressures feel like in the emergency ward?

I think looking out the patients in the corridor is a bit that I find the hardest to deal with.

So you find yourself constantly apologizing because that isn't good care.

It doesn't give people the respect they deserve, the privacy they deserve.

You're trying to take histories, sometimes quite sensitive histories.

You might have this little barrier that you put between each trolley to give the illusion of privacy.

They're not soundproof and you're trying to ask people about all the details of their lives and their families while people are coming and going and the corridor is still being used as a cut through to other wards because you can't close off either the hospital.

By then trying to examine patients, you then are trying to either find a space that you can hopefully temporarily use or you're trying to hold off a blanket.

So just examine around it and it's just it's not the care that we train to deliver and you just feel awful for the patients.

And it's not fair on staff either.

It really affects your morale because none of us chose to go into this work to treat people like that.

On top of that, we know that delayed care and care in the corridor often leads to worse patient outcomes.

And so you're much more likely to see significant events and patients having poorer outcomes because of the care they're receiving because you can't do all the things that you would normally do in a timely manner.

Even things like if someone comes in with chest pain and you're trying to get an ECG, ideally that ECG should have done in 15 minutes so that if they're having a heart attack, you are straight away aware of that and can get them to the right place.

If they're in the corridor and you can't get the ECG machine there or it takes longer to get it, you take longer to diagnose it, they take longer to get a treatment, their outcomes are worse.

There has been the Royal College of Emergency Medicine did some research to say that there is also a death associated with those long wait times in that corridor care.

I think they estimated in 2023, there were 14,000 extra deaths because of delayed care in A&E.

By that, they defined it as patient waiting more than five hours.

So, there's real serious patient harm that happens because of these rector pressures.

That figure is really striking about extra deaths, but I guess also from what you're saying, not just deaths, but the fundamentals of good patient experience around experiencing kind of dignity and respect when you're in hospital.

It must be really hard to get satisfaction in work when you're aware that care is being delivered in that way.

Absolutely.

It completely destroys your satisfaction in the work that you're giving, at least to low morale.

And we know that productivity is low at the moment, and actually people are working harder than ever.

But when you're working in such a saturated system, you can't be as productive.

You spend as much time as you can rearranging the corridor and trying to move patients.

And so actually you're not focusing on patient care and treatment and outcomes.

So it's just, it's awful.

Charlotte, let me come to you.

I actually saw a survey from NHS providers last week.

You probably saw it too.

It said over nine in 10 trust leaders were concerned about the impact of winter pressures on their trust or local area, which I think kind of resonates with what Kelly's just been saying.

It's like nine out, over nine out of 10, it's pretty much a universal concern.

From your perspective, looking across the kind of health and care sector, why is winter such a difficult time for the NHS and social care sector?

And do you think there's anything that makes this year different from other years?

I think with winter, you get the kind of perfect storm of colder weather, which can exacerbate some conditions, but then also brings its own real mix of, I don't know, a bag of tricks itself.

So you get seasonal illnesses.

So you have flu, winter vomiting bugs, and respiratory conditions like RSV, that really affect patients and staff alike.

And I guess the end result is that year after year, hospitals get fuller, GPs are swamped, and patients end up waiting longer for care.

That's something that we've seen kind of borne out year after year.

And we're already starting to see that in some of the figures, performance stats that came out last week.

So we've seen that the number of people being admitted, transferred or discharged from A&E departments has come down from 74.2% in September to 73% this October.

And the target is actually 95% of people.

And so we've not really seen that met in years.

And then we also have that pressure replicated across the system.

So it's also in ambulances.

So people are waiting on average 42 minutes for an ambulance for urgent cases such as strokes, when the target is 18 minutes.

That target's not been met in four years either.

So I think that really shows that the pressure that the service is under, alongside the fact that there's 6.3 million individuals representing 7.6 million different cases on the elective waiting list.

So this year feels really tricky because there's two aims that the government has, really, and that's about moving care into the community, but also trying to reduce the elective waiting list.

And unfortunately, when A&Es are packed, that feels much harder to do.

And I'm sure Kelly can reflect on that.

We've not really had summer in the way that you traditionally would, which you'd see a kind of break in some of these performance stats being slightly better or looking like the performance has kind of started to improve before you go into winter where you do see a deterioration in performance.

And I think this has come home to me as someone who works on policy.

More recently, I was hiking up in Wales and I just thought, what happens if I fall?

And I've quite often I've thought that, but I thought, oh, the NHS will be there for me when I need it.

And I think it's been a conversation that colleagues have had more and more about what happens if I slip on the steps at the tube getting off or those kind of things.

You just you feel the intense sense of dread not from a perspective of working in the service, but a perspective of someone on the outside looking in and just thinking how unrelenting some of this pressure is.

I just wanted to like, I totally agree and to come in there just as an example of just last week, we've had patients who waited two hours for an ambulance with limb thrumpling injuries.

And so that's a really true real life example.

It's not a, it's a genuine concern, you know.

Sadly, I can't sit here and reassure you that if you did fall down and had a nasty ankle fracture, that the ambulance will be there in five minutes as important to me, because that just isn't our reality anymore.

And I also wanted to jump in about the elective waitlist, because we 100% see the repercussions of that.

Particularly, I find it, we find in A&E with mental health care, and we see people with really acute crises of their mental illnesses, coming to A&E as a last resort and as a place of safety.

And for those people, A&E is just an awful environment to be in.

It's loud, it's noisy, the lights are constantly on, food is the sandwiches, it's not hot meals.

And actually, when you're at that crisis point, to think that somewhere like A&E is the only place you can go, it's really sad, but we know that people are waiting such long times to get the care in the community that they need, that there isn't an alternative.

Yeah, it takes me on actually, Kelly.

I wanted to ask you a bit about health inequalities.

And I know it's something you think about a lot in your work, but do they widen during winter?

I feel like the example you gave there was one potentially where there are groups of people that are going to be impacted more by these pressures we're describing than others.

I wonder what your perspective on that is and what you've seen in your work.

I think the research shows, and my personal experience definitely backed up, that health inequalities are hugely impacted by these winter weights.

So we know that people from more deprived areas and backgrounds are more likely to use A&E in the first instance, as a call for any new illnesses or injuries.

And so they're already more likely to be in A&E.

And there are some studies that show that once they're in A&E, we know that actually the quality of the care that they get isn't as good as those from more privileged backgrounds.

They tend to wait longer in A&E.

They're less likely to be admitted under specialty teams and more likely to be discharged.

And so when you already have that inequality built in as a background, and then on top of that, you add the winter pressures, it definitely serves to widen those inequalities, which again just leads to worse outcome to people from more deprived areas.

And Kelly, when you're working in the hospital during winter, do you feel like you're working in the hospital doing this, or do you feel like you're working as part of a system?

I think it's variable, depending on the hospital you work in and what the system is like.

Where I work at the moment, we have an amazing urgent community response team, particularly for elderly patients who we can contact and they can visit patients the same day if we discharge them and get things set up in the home to avoid adventures, get them equipment, get them emergency care packages.

Situations like that, you do feel really linked with the community services and like a team.

But often I think, and again, it's when people are completely stretched, sometimes you divide down into your individual teams and you think, it's almost like an us against them.

And you can sometimes hear the attitude of, oh, why have they sent this person in?

They should have done this or we're too busy.

It's not our job to deal with that.

I think it does depend on the team you're working with and how well those links are established because it can be kind of a bit of an us versus their mentality just to try and get through the day.

Yeah, you need those really strong established relationships to get you through the tough times, I guess.

Yeah, definitely.

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Welcome back.

Charlotte, I don't know if there's anything you see looking across the system around how the different parts work together at this time of year.

Unfortunately, the kind of problem with winter is it's kind of characterized by how it doesn't work that well together and how there isn't that kind of bigger picture look at what each part can do to work together on some of this.

And I think, as Kelly kind of highlighted, the Urgent Community Response Teams are an amazing thing.

But I think it's the same with some work that The King's Fund did looking at discharge, that where those kind of local relationships weren't really well established, there were real issues with trying to get the system to have the same goals in mind.

And I think if you look at some of the discharge data, there's a real misconception that a lot of people are still in hospital beds because there's a problem with social care.

Yes, that is a part of the problem, but sometimes people are medically ready to go.

But unfortunately, there are things in the hospital that's keeping them there.

And so I think it can very quickly become a kind of, as Kelly described, like a bit of a blame game.

Like this is the fault of someone else somewhere else.

But, and I think that's kind of why when winter really does, the pressures really do kind of become really visible.

Part of that is a kind of breakdown in the system and how all the different constituent parts, kind of people's access to general practice, all that kind of stuff.

A lot of that is when that breaks down and people feel like going to A&E is their only option or those kind of things.

I think that's, it's kind of one of the things that really shows when the system isn't working and pulling in the same direction.

Yeah, it's really interesting to think about the cause of the blockages and the pressures and how different people experience them.

That survey I mentioned earlier was the kind of trust leaders.

The most common reasons people were concerned about winter pressures were financial constraints and staffing provisions or how they described it.

I don't know, Kelly, how does it feel in your role?

What do you see as the causes of the blockages and the things that are making it more pressured for you?

From an A&E perspective, we often talk about flow through the hospitals being one of our big issues.

So actually over the last year or so, the A&E numbers in terms of people presenting aren't hugely different from previously.

It's not that suddenly we have so many more people coming into A&E in the first place than we ever used to, but we do have a problem with flow through the hospital.

So in our department, you might have 30 to 40 patients who are waiting to be admitted to a ward.

So they have what we call a decision to admit.

If you take out 40 bed spaces from our A&E, even if we are seeing patients quickly, you massively reduce our productivity.

Because then there's no way to see that new patients are coming in, no way to give them treatments.

Then our A&E nurses are then effectively looking after ward patients.

So they can't also be doing all of the treatments for our new patients coming in.

So that's what hugely slows down the flow to A&E for us.

And then we get the numbers that Charlotte was talking about in terms of only 74% or less DMC within the four hours.

And I remember when I first started working, we did achieve the 95% target.

And that feels like another world now, that it would be impossible to ever do that.

And I kind of really feel for the more newly qualified staff and those who don't even have that memory to lean back on, who think that this is just always how it's been, and actually it hasn't.

And we can definitely do better.

And I think things that affect flow are like bedstays in the hospital.

And as Charlotte was saying, there's lots of things that slow people's discharges, waiting for imaging or waiting for not necessarily care homes, but packages of care or equipment.

And there's so many different factors that go into it, but because the number of beds we have has gone down over time, we just don't get that flow through the hospital.

It means that we have to come up with new strategies and things like onboarding that wards use now, where it's effectively what we do in A&E, the corridor, but on the ward.

So they might send one or two patients to onboard in a ward, so effectively wait in a corridor space or what wasn't a traditional bed space, waiting for another patient to be discharged so that they can take that space.

So some of the pressure is taken off A&E.

It's so interesting what you're saying there about there effectively being this whole generation of doctors and other staff in the NHS that haven't experienced a winter which isn't in crisis, basically, I think you're describing.

And I just wondered, what was it like when you were meeting that 95 percent target?

Did it feel fundamentally different, like no patients in the corridors or?

Oh, it was lovely.

It really did a bit, I mean, I was lucky, I only just got it because I qualified in 2013.

People sort of talk about the late 2010 side of being really great for that.

But even when I started, for example, overnight, you would clear the A&E board, so you would see every patient and everyone would either be admitted or sent home.

And sometimes at three or four in the morning, there'd be no one in A&E.

And you actually felt so satisfied with the care you were giving, that everybody had been sorted out.

It was great for team morale because you had this little dip.

And it might only be half an hour or an hour where everything was much quieter.

But that was the time that you could do a bit of teaching with.

At the time I was an F1 or F2, so the registrars might do some teaching with us, or we would just sit and that bonding time as a team.

So you felt really connected.

And then normally around four or five in the morning patients would start coming in again.

And you wouldn't also be handing over.

Often now I find, especially after a night shift, when the morning team coming, you're apologizing for the state of the department that you're handing over.

I'm so sorry we went really hard, but there's still 10 waiting to be seen, and there's patients waiting 48 hours for bed, but we tried, da, da, da, da.

The conversation constantly feels negative and apologetic.

Whereas before, you felt proud handing over a great department, knowing that patients who had good care.

And morale was just a lot higher.

And I do still hope we can go back to that.

Yeah, it just shows you that kind of virtuous cycle that happens when things are going well.

Like you're talking there about learning and extra training that happens.

You can get to connect and build as a team.

You're getting like more stuff satisfaction.

And just thinking about what it means to not have that anymore must be difficult.

Charlotte, can I ask you, we talked about so many different factors that are affecting winter pressures.

How much do you think is determined by national policy and funding?

And how much is down to local relationships and context?

So I think the national kind of context is set by NHS England and kind of the expectations from this to the system and to the kind of uniform performance that NHS England expect has kind of been set out in a number of different plans over the years.

We're kind of in the second year of delivering the Urgent and Emergency Care Plan and the winter letter that went out this year in the beginning of September, because it's good to be prepared for winter.

That kind of set out that continuity of the delivering the Urgent and Emergency Care Plan was the kind of thing that was going to be expected from the system as a whole.

So it really, it kind of sets the tone and I guess the direction.

And I think what really struck me reading this letter, because I read quite a lot of them, was that they just said that unfortunately, despite all the plans, they still expect that winter this year, many people's experience of care will fall really short of what is expected.

And I thought that was really striking that that was already kind of prefigured and put in the letter when we thought about this back in September.

And so I think a lot of the kind of the national things come down to kind of how much money is available in the system to support winter.

But a lot of that money does tend to come really late on in the day.

How can systems spend money that's given to them kind of in September or October, sometimes even in November or December, that will then make winter look better because it's not an effective use of money.

But thinking about local context, I think it's been really demonstrated that it does come down to what relationships you have in a local place as well, because the national policy can only tell you so much, and it can give you a framework for how you're going to act.

But actually, that has to be translated into your local context, to your local A&E.

Do you have an urgent care center that you can divert people to or not?

Those kind of on-the-ground decisions will always be determined by the local context and what is going on in the rest of the system.

Kelly, let me ask you a bit more about, I guess, your experience.

It's such an intense time for many staff during the winter.

And you're under more pressure at work as well as kind of higher risk of getting ill yourselves.

And I just wondered how you look after your own well-being and the kind of health and well-being of your team during winter.

So you're probably here today.

I actually have got a cold right now.

So apologies for that.

And that is something you do in obviously quite higher levels of staff sickness as well.

A lot of staff had children also in the local area.

So it's just a merry-go-round for fire and illnesses.

You kind of have to look after each other.

You have to do your best to try and stay positive, still check in with people.

When we're having handovers at the start of the day, in the middle of the day, you just need a couple of minutes just to ask people how they are.

It doesn't, it's not gonna make any difference to the whole day, the flow of the day, or how long it takes to wait just to have a couple of minutes to backtrack.

But I think it's so important for people to feel valued and appreciated.

And you can see when that isn't there, or on days when there might be conflict with other members of staff, how it just affects the whole team.

And when morale is already low, you just can't afford for it to crash any lower.

And again, for the benefit of the staff, but also because that affects patient care.

Things like the Christmas party are important, I think.

And that comes up in winter.

So you just need to often ask hospitals for sports teams, things like that.

You need, we're doing an ED Oscars at the moment.

So nominations, little things like that.

You just need something to keep people fully connected and appreciated.

And at the end of the night, just being like, thank you everyone for your hard work.

Because you can walk away, despite having worked very hard, feeling like you haven't achieved anything.

So it takes a long time.

So I think you have to do to try and keep morale up.

Yeah, that makes sense.

I don't know, Charlotte, if there's anything you wanted to add about staff well-being or staff sickness.

I think I just wanted to reflect that we've talked about productivity quite a lot in this conversation already.

And I think it is really difficult as a word.

And I think the focus on it politically has really been quite challenging in the sense that people really feel like it's telling them they're not working hard enough.

And I think just listening to Kelly makes me reflect on how it's just not the right term, I think.

And we're not really going after the things that matter to staff if we talk about productivity.

So we're not talking about the value and the kind of quality of care.

And what's really coming through to me from this kind of conversation is listening to Kelly talk about the fact that it's not the quality of care that they want to be giving to people.

And that, I think, means more than productivity, which is quite a cold term.

I'm really glad you said that, actually, because I was shuddering with that word, productivity.

And I know what it means, technically, and why that means the productivity is technically lower.

But in terms of how much people are doing day to day, it feels like, if anything, people stand for doing more, because, especially from an A&E perspective, you're looking after ward patients and your A&E patients.

It's not very productive to call five times to try and chase a bed space, but that's a lot more work than before, when we weren't as busy, and you just called one to the bed space, all right.

So actually, you're repetitive, I guess, and you're doing the same tasks again and again, which is quite productive in terms of you're doing a lot.

It's just that your outcomes aren't there because you're repeating yourself the whole time.

So yeah, it does feel like quite a harsh word sometimes to hear when you're working day to day and then you turn the news on.

It's like, oh, you've had more stuff than ever, but your productivity is so low.

Yeah, and I think actually it was really nice in the Darzi report that he kind of front and centred that and said, you know what, not being productive isn't just bad for the health service and the kind of performance that it has.

But it is also really hard for staff because it drains the enjoyment out of the tasks they're doing.

Charlotte, winter pressures, it's such a political symbol.

It's something that you can kind of expect to see big stories in the headlines about in winter, corridor care, horrible stories about people dying in ambulances.

This will be the Labour government's first time leading us through a winter in 15 years.

And I just wondered, when we look at what they've done so far, what does it tell us about their approach to running the NHS in general?

So I think one of the first things that West Regent did was he got round the table with the BMA and put an end to the strikes by junior doctors.

And I think that was really important because winter is made worse if there are people on strikes because it's just an extra disruption in an already really busy time.

I think because it happened so early on, I think it's very easy for people to dismiss that as something that's been done and that's fine.

Actually, I think that's really important.

And then there's also been the kind of idea of this government coming in and wanting to take a much more substantial view about what has been going on in the NHS and social care to a lesser extent, but what has been going on in the NHS over recent years, and really taking a diagnostic approach to looking at what's going on, and then what needs to happen to be able to get the NHS back on its feet and fit for the future.

So the kind of the Darzi review happened in September, and now we're in the phase where the public is being consulted about what they want to see in a 10-year plan for the NHS.

So there is a kind of sense that there's a long-term aim that's being worked towards, and that 10-year plan will look to kind of end this cycle of crises and kind of short-term thinking.

But at the same time, I think from the budget, we kind of got the sense that while they're very focused on that and very focused on the NHS, some other parts of the system, particularly social care, have kind of completely dropped off the radar, and you won't really fix the issues in the NHS unless you have a plan for social care.

And I think the absence of a plan at the moment is really quite worrying.

And it does feel a bit like in the pursuit of long-term aims and goals, which are so important, and I really wouldn't want to say that they're not, you do still have to have a plan for the immediate crisis at hand.

And it does feel a bit like this winter has been kind of like, okay, we'll see what happens this winter.

It will probably be quite bad, but let's just see what happens.

And I think that's really difficult.

And I think it'll be really difficult for the public to accept having voted for what they consider to be change.

So a different approach to have still the kind of the same repeating things that you'd see, like you said, in the kind of newspapers, people in corridors, people waiting ages in the back of ambulances.

I think that will be really, it will be a real test of this government, I think.

Yeah, so we're in this strange position where really what's potentially going to be a very, very difficult winter is coming up, but the system is in a holding pattern waiting for the plan.

And the plan's not going to come until May.

My final question actually is to ask you what you think policy makers, system leaders should know about the system.

You're there dealing with this day to day.

What do you see and what would help?

What do you want them to hear from your experience?

I think acutely, for an A&E inspector, it's flow and bedstays in the hospital.

And that's hugely impacting the care we can deliver, and it's affecting patient outcomes and our staff.

So I think in the short term, that's definitely our main concern.

I think, and maybe this isn't just for national policy leaders, but also for us locally.

To me, it's really important that you have that local community connection and network from a population health perspective.

Really integrating our hospitals as anchor institutes within our local community is something I think is going to be essential if we're going to move towards addressing the health inequalities that we see.

So in a longer term, that's something that's like the kind of consultant that's definitely something I would have focused on and try and implement in my own public health.

I think that's key to addressing inequalities and then also as an effect, improving the situation for the NHS.

Thanks, Charlotte.

I don't know if there are things you'd like to say to policy makers and system leaders about the winter pressures, things you think they need to hear.

I think for me, it's just I've had this conversation so many times, like just the anticipation of thinking that winter is going to be bad and then it does turn out to be bad.

I would love to see some movement that means we're not in this inevitable cycle of a kind of a difficult winter being a kind of thing that staff have to go through and that patients have to experience.

And I think it's the aims and the kind of ambitions I talked about around the 10 year plan.

I think those are the right goals to go for.

I just really think that it's really difficult to see how that's going to change things in the immediate term.

And unfortunately, that's quite stressful when you're thinking about people you love seeking care at the moment.

And that's really, it's quite a challenging thing.

But I don't think that the immediate crisis should distract from the kind of the long term goals that will hopefully be the solution to that immediate crisis.

But I do think it's really difficult to hold that in your mind when you're facing stuff, like looking at the news and looking at people having care in a corridor as a kind of regular thing.

Thank you.

I'm struck by the really difficult experiences we've been talking about today for staff and patients.

And that kind of dread you spoke about Kelly as we come into winter.

I feel like our conversation has really illustrated why you would feel that.

And we've just been talking about care mainly in the emergency department, but I'm sure we would have had a whole different set of experience set out to us if we talked to people working in community based roles or in care homes.

But I think the one thing that really stays in my mind from our conversation is Kelly, you talking about the beginning of your career and how you described the way a shift on the emergency ward and the A&E was different at that time.

So it's not inevitable that it feels like this.

A bit of a sense of hope as we start to develop a new plan for the health service.

But that's all we've got time for today.

Thank you to Kelly and Charlotte for joining me today.

Thank you for having us.

Yeah, thank you so much.

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