The extraordinary pressure being placed on London A&Es can be revealed today, as hospital bosses said they feared the worst winter yet seen by the NHS.
The majority of the capital’s 18 trusts with A&E departments are on “black alert” – the highest status – on a daily basis. On one afternoon last week, Hillingdon, Barnet, North Middlesex, Homerton, Newham, Queen’s and the Royal Free were all simultaneously “black”.
Croydon had “no beds across the trust”, the Whittington had no medical or surgical beds and the £650m Royal London – one of four major trauma centres in the capital – had no trauma, neurological, orthopaedic or medical beds. Whipps Cross had no capacity in its intensive treatment unit, critical care unit or paediatric wards.
The Evening Standard was invited to visit three hospitals – Barnet, Croydon and St Helier – to see the scale of the challenge faced by front-line staff. At Barnet, indicator boards in the operations room provided live status updates across London and beyond, from ambulances waiting outside A&Es to the minuscule amount of spare capacity within the system.
Doctors and hospital managers vowed to do everything possible to prevent “crisis” events, such as patients waiting 12 hours on a trolley or ambulances being diverted to other hospitals. However, all admitted the main A&E target – to treat 95 per cent of patients within four hours – was almost certain to be breached.
Problems are expected to peak on the first week in January, traditionally the worst week of the year for the NHS, when many families “hand back” care of elderly relatives to hospitals and care homes.
Kate Slemeck, chief operating officer at Royal Free London NHS Trust, which runs Barnet hospital, said: “I think we are fully expecting winter to be really tough.” Jackie Sullivan, chief operating officer at Epsom and St Helier, said: “We will have days when we will absolutely fail the A&E target, without a doubt.”
Last January, Croydon was forced to declare a “internal major incident” and temporarily close its A&E. This year it is “better prepared” due to the opening of the “one-stop shop” Edgecombe Unit that provides rapid treatment to almost 2,000 patients a month who would otherwise be treated in A&E. Chief executive John Goulston said his biggest concern now was his own staff falling sick.
Consultant physician Dr Reza Motazed said the unit was “helping to unblock delays in A&E” by focusing on GP referrals, elderly patients and those with chronic lung disease, blood clots or skin infections.
“It means our patients can be seen by senior hospital medical staff within hours for early clinical decision-making – something that is not always possible via the traditional A&E route,” Dr Motazed said. Croydon hit the four-hour target last month and in the first week of December.
One patient, Arya Tabatabaei, 22, was referred to the unit by his GP to test for low levels of the hormone cortisol after suffering anxiety and lethargy. His father, SD Tabatabaei, said: “I have lived in Croydon for 40 years and we used to avoid this hospital at all costs. This is a huge surprise. I never saw this before, even under Bupa.”
St Helier, in Carshalton, where former Prime Minister John Major was born, also focuses on the rapid assessment of patients by a senior doctor. All ambulance cases are “RATted” – code for its new rapid assessment and treatment system – by a registrar, while walk-in patients are assessed by a consultant. Swift diagnosis and treatment of minor cases clears the way for more time to be spent on sicker patients, emergency department clinical director Amir Hassan said.
About 250 patients a day attend St Helier’s A&E, and up to 170 a day at its sister hospital in Epsom. Attendances are up six per cent on last year, with the degree of sickness – or acuity – rising.
Mr Hassan said: “I have got the feeling this year is probably going to be worse than last year. The [patient] numbers are higher and the acuity issues are still there. We have got quite an old population in this area. At Epsom, the whole hospital is like an elderly care ward.”
After a “terrible” day at St Helier on Monday last week [Dec 14], bosses decided to keep the urgent care centre open until midnight for the rest of winter to prevent flooding the main A&E with “minor” patients and breaching the four-hour target when it closed at 10pm.
Ms Sullivan said: “We have got to prevent people coming to the front door while making sure we keep the back door open. With 30 to 40 admissions a day, if we don’t get that sort of discharge we will run into difficulties.”
At Barnet, (pictured above), clinical site manager Kate Rock visits each of its 15 adult wards in the morning to assess how many patients can be discharged that day – and then makes two return visits in the afternoon to check how many have been sent home. The previous day it had achieved 40 “home for lunches”. That day’s target was 60. The need for inpatient beds was pressing: at 9am there were 35 people in its A&E, of which eight were awaiting to be admitted to a ward.
Managers say Barnet, which has 321 adult acute beds, has been at 100 per cent capacity “for years”. More than 300 A&E attendances or 80 ambulances heralds a frenetic day. “We are the only part of the healthcare sector that can’t say: ‘Stop!’ said Claire Nash, Barnet’s general manager for patient flow.
Across the Royal Free’s three hospitals – at Hampstead, Chase Farm and Barnet – up to 100 patients a day are medically fit enough to be discharged or transferred to “step-down” rehabilitation beds but cannot leave due to inadequate provision in the community.
One of Barnet’s biggest issues is the extra patients it receives when weaker hospitals, such as Northwick Park, in Harrow, or Watford General reach crisis levels.
“If Northwick Park and Watford are not coping with the pressure, London Ambulance Service or East of England Ambulance Service start diverting away and bringing us more work,” Ms Slemeck said. “There is a risk of that toppling us over. If we could all hold our own, we could probably cope. We all need to consume our own smoke, but it’s easier said than done.”
Dr Turan Huseyin, clinical director of emergency services at Barnet, said one perverse effect of the four-hour target was that “someone with a sore big toe” had the same right to speedy treatment as those who were dying.
“I can ring my GP with my big toe problem and they will see you next week,” he said. “But I can walk into A&E and know I have to be sorted within four hours. I honestly think the four-hour target needs to be thought through and refined. If you have got to wait eight hours, so what? You are not going to die. If you take away this target you will save a lot of money and maybe re-educate the population.”
One mother, Roza Kukucska, brought her son Balint to Barnet A&E because she was unhappy at their GP’s plan to treat his chest virus with antibiotics.
“He has been given antibiotics seven times and he is only two,” she said. “He was wheezing and coughing and had a bit of a temperature. I didn’t believe the answer would be another course of antibiotics.”
Balint was given drugs to ease his breathing and was kept under observation for several hours after being seen by a paediatric registrar. “I feel much calmer at the moment and much more reassured than if I went to the GP surgery,” she said.
Barbara Levy, 63, was rushed to A&E at 3am from her home in Mill Hill after suffering a suspected heart attack. “It was excruciating,” she told the Standard. “It was like someone was sitting on my chest.”
The care was “excellent but could be quicker”. But she doubts the medical diagnosis – believing she had merely suffered indigestion after eating chestnuts. “I think I overdid it. I think that is all it is.”
Her daughter Claudia Nicholls says of her mother: “She doesn’t do hospitals.” Doctors admit Mrs Levy to a cardiology ward for further tests and observation. Emergency department matron Loraine Chowdry sympathises: “The most comfortable bed is the one at home.”
Dr Andy Mitchell, Medical Director, NHS England (London) , responding to the Evening Standard’s findings, said: “It’s vitally important for Londoners to know that in all my years of involvement in preparing London for ‘winter pressures’, the system is better co-ordinated and in a higher state of readiness than ever before. Winter is the busiest time of year for the NHS. Staff, not just in London but across the country, experience immense pressure in meeting the needs of patients, no matter what part of the system they work within, be it primary, community, social or hospital care.
“At every opportunity we have been encouraging patients to play their part. This means ensuring they are immunised against flu where it is appropriate, and turn first of all to sources of advice such as 111 and local pharmacies rather than A&E. However, where hospital care is necessary, we will ensure that the sickest patients have priority. This may mean those who are less unwell waiting for longer periods, but we remain dedicated to providing the highest quality care. Although targets may not always be met as we would like, it does not mean the service is unsafe.”
An edited version of this article appeared in yesterday’s Evening Standard: http://www.standard.co.uk/news/health/london-aes-brace-for-their-worst-winter-crisis-a3143836.html