Select Committee on Welsh Affairs Minutes of Evidence


APPENDIX 6

Memorandum submitted by The University Hospital of Wales

EMERGENCY ADMISSIONS

1.  INTRODUCTION

  We are very pleased to have the opportunity to make this submission to the Welsh Affairs Committee.

  The UHW has experienced the significant increases in demand for emergency admissions during the winter as other hospitals across Wales. However the nature of the pressure in a Teaching Hospital and Regional Centre is inevitably different to that of a District General Hospital, given the range of specialities and the complexity of the cases admitted.

  The paper describes the context for emergency admissions amongst the many other pressures in the Health Services in Wales. It then goes on to describe the impact of emergency admissions on the UHW and the work we have done recently to cope with this. The paper then covers our plans for using the new money available to us from the Government's initiative and sets out some of the issues surrounding this. Finally the paper sets out our plans for the future and draw some conclusions from this.

2.  THE CONTEXT

2.1  Emergency Admissions and the Changes in the Health Service's in Wales

  The pressure of emergency admissions must be considered in the context of the many other changes and developments in the Health Service in Wales, and in Cardiff in particular. For example:

    -  The planned closure of the CRI and the associated transfer of the A&E Department, resulting in a comprehensive Teaching Hospital on the UHW site;

    -  The development of the Cancer Centre in Cardiff;

    -  Our plans to develop new services in the UHW for the people of Wales, such as Heart Transplantation.

  There are also the uncertainties of the All Wales Acute Services Rationalisation Project which is due to report soon and, inevitably, Trust reconfiguration and how this will impact on acute services in Cardiff.

  These changes are also set in the context of the very real funding difficulties ahead, as set out in the Health Authorities forecasts. The proposed shift of funds from secondary to primary care is at a time when the costs of the new technology, drugs and new treatment regimes are increasing. In discussing emergency admissions we must also consider the funding pressures within Social Services Departments, which affects our ability to discharge patients.

2.2  The Rise in Emergency Admissions

  Much work has been done to analyse the reasons for the rise in emergency admissions. The reasons include the ageing population; increased patient expectation of hospital care; a rise in the medical problems requiring hospital treatment; and social changes such as the decline in the extended family and the levels of deprivation in society. It is our responsibility as a provider of emergency hospital care to ensure that we provide a high quality and effective service for this group of patients.

2.3  Emergency Admissions and the Targets for Trusts

  Trusts are required to deliver against the three statutory financial targets; meet contract targets; achieve Patient's Charter standards and respond to the service pressure associated with the rise in emergency admissions. These requirements are often incompatible, for example dealing with all emergencies can mean cancelling elective patients, leading to a rise in waiting lists. This can also lead to an increase in our spending over and above our contract income because emergency patients often cost more to treat. It is therefore important that Trusts are given clear priorities for the targets we are required to achieve.

3.  THE UHW POSITION

3.1  Emergency Admission Pressures

  The UHW Trust is the major provider of emergency care in Cardiff. This extends beyond Cardiff for some of our Regional Services. Currently around 60 per cent. of our inpatient activity and 50 per cent. of our inpatient costs relate to emergency care across all specialities.

  When considering the rise in emergency admissions it is important to appreciate the seasonal nature of the demand, with more emergency admissions in the winter months. These patients are often more poorly and stay longer than in the summer months. This puts further pressure on the beds in the Trust with the increasing danger of having to close to admissions-something we have never done and will do everything to avoid in future.

  For these and other reasons described in this paper, it is vital that we manage emergency admissions well and do this at the same time as achieving our other required targets and plans. The Trust Board has therefore agreed to commence a special "Emergency Stream Project" with a top team of Doctors, Nurses and Managers leading the way. This is described in more detail later in this paper. The main focus of this project is to improve the quality of our emergency services whilst recognising the very real need to reduce our costs.

3.2  The Impact on Elective Admissions and Waiting Lists

  One of the responses to increased emergency admissions is to use the beds previously designated for elective work. This is undesirable for several reasons. Firstly it is not fair to those patients who may have been planning their admission for some time, to be cancelled at relatively short notice. Secondly our waiting lists grow and we may be unable to achieve the Patient's Charter Standards in some specialties. Rightly or wrongly, long waiting lists are seen as an indicator of inefficiency in hospitals. In reality a hospital could be dealing very effectively with a large rise in emergency admissions but at the same time having to cancel waiting list patients to do so. Treating emergency patients is the priority for the patients, General Practitioners and hospital staff.

3.3  The Effect on Trust Income of Emergency Admissions

  Cancelling elective admissions also impacts on our income and hence our financial position since we may not be able to meet our contract targets for the Health Authorities. Also we may have to cancel GP Fundholder patients who may be in a cost per case contract, when we would lose the income for every case cancelled.

  During 1996-97 we estimated this income loss to be a minimum of £250,000. We believe that a new contracting framework is needed: (a) to stop Trusts being penalised through losing income when dealing with emergency demand; (b) to recognise that the additional costs of the extra emergency cases cannot be offset by an equal reduction in the costs of elective cases (the cost of an emergency admission is higher than the cost of a routine surgical operation); and (c) to recognise that emergency cases admitted to the UHW as a Teaching Hospital are often more complex and therefore cost more.

3.4  Collaboration Within Cardiff

  Together with the Llandough Hospital Trust we have recognised the need for joint working and a joint approach on the management of emergency admissions. In particular we have submitted a joint paper to Bro Taf Health Authority to resolve our concerns about the potential loss of income this year and the problems of our waiting lists rising as a result of dealing with the rising number of emergencies. Competition in the Health arena has prevented much good work of this nature in the past and we welcome the new approach towards collaboration and co-operation. The natural conclusion of this would be to have one Trust for acute services in Cardiff.

3.5  The Impact on Teaching and Research

  We are aiming to be one of the leading Teaching Hospitals in the UK and at the forefront of Research and Development. Unlike District General Hospitals, a Teaching Hospital has combined responsibilities for clinical services, teaching and education and Research and Development.

  We need to ensure that we discharge our responsibilities in these areas whilst dealing with the demands of emergency care. This does pose problems in that the higher number of emergency admissions can take Consultant time away from teaching. Also, the cancellation of elective surgery can mean that trainees do not gain experience in the full range of cases.

4.  THE UHW PLAN FOR MANAGING EMERGENCY ADMISSIONS

4.1  Developments to Date

  In ensuring both an efficient and proactive approach to the management of emergency admissions, the UHW Trust has developed and implemented a number of initiatives, which have improved the throughput of patients within our Hospitals. These initiatives, which have evolved over the past 18 months, have been aimed at:

    -  Improving GP access to emergency services within the Trust;

    -  Improving the system by which hospital beds are managed and admissions are coordinated; and

    -  Improving discharge planning practices.

4.1.1  Improved GP Access to Emergency Services

  In April of this year, the Bed Bureau service, which was previously managed by the Southeast Wales Ambulance Trust, was transferred to UHW. This service coordinates admissions on behalf of GPs within the Cardiff area and is essential in helping them to manage their emergency workload. Although already a well established service, the Bed Bureau has been further developed since transferring to UHW:

    -  The Bed Bureau Service, which previously worked in isolation from the hospital, has now been joined with the Trust's Bed Management Centre Service. This combined system has both stream-lined and improved efficiency in terms of expediting patient admissions, ensuring bed availability and reducing waiting times for patients in the Emergency Admissions Unit. They also coordinate admissions across UHW, CRI, Rookwood, West Wing and Lansdowne Hospitals.

    -  The Bed Bureau now offers a consultation service, which allows GPs the opportunity to discuss the patient with a Consultant, before deciding upon an admission. Such a service provides GPs with a support mechanism by which to obtain a second opinion or arrange for the patient to have an urgent review and may provide an alternative to a hospital admission.

4.1.2  Improved System by which Beds are Managed and Admissions are Coordinated

  Prior to February 1996, there was no formal system of bed management within the Trust. Patient admissions were arranged by individual wards, which worked in isolation and which were often unaware of the bed pressures being experienced throughout the remainder of the Trust. Such an approach to the organisation of patient admission, did little to ensure the most efficient use of beds. Having identified a problem, the Trust developed a Bed Management Centre Service, with designated staff being given responsibility for coordinating both elective and emergency admissions. The benefits and achievements of this service are as follows:

    -  All admissions are now organised in a coordinated manner across the entire Trust, with the result that bottlenecks associated with patients admissions have been reduced.

    -  The profile of bed management has been raised, with the Trust highlighting this issue as a corporate responsibility and staff being more appreciative of the measures needed to deal with bed pressures.

    -  In ensuring efficiency, the Bed Management Centre has promoted a more flexible use of the bed resource. Such an approach has enabled the Trust to cope with changes in demand associated with both elective and emergency activity.

    -  The constant monitoring of bed availability, ensures a proactive approach to bed management, with the early detection of impending bed shortages and the instigation of contingency plans.

    -  To support the Bed Management Centre in its function, the Trust has developed an Admissions/Bed Management Policy. This policy promotes a "staged" approach to the management of potential bed shortages and is aimed at ensuring that the Trust can continue to accept emergency cases.

4.1.3  Improved Discharge Planning Practices

  It is well recognised that if discharge arrangements are inefficient, patients stay longer in hospital than necessary and our capacity for dealing with more emergency patients is limited. We therefore conducted a survey last winter looking at the reasons for the delay in discharging patients. From this work it was clear that improvements in discharge planning practices were needed. As a result, the following initiatives/ developments have been undertaken:

    -  Two Discharge Coordinators have been appointed, as a pilot scheme, to work within the Integrated Medicine Directorate. These staff are responsible for facilitating the discharge planning process by both educating nurses and doctors in relation to effective and safe discharge practices and by promoting a proactive approach to discharge planning.

    -  The Trust's Discharge Policy has been revised in order to reflect/promote a proactive approach to discharge planning.

    -  A dedicated ambulance vehicle has been commissioned to deal with short-notice discharges and transfers.

    -  The Bed Management Centre has been extended to include the co-ordination of transfers to all Trust sites and other hospitals. This initiative has reduced the delays associated with transferring patients from the acute sites to our Rehabilitation/continuing care beds.

    -  Having identified access to rehabilitation facilities as being a common cause of discharge delays within the acute site, the Trust has recently increased its number of rehabilitation beds. In enhancing this service, it is hoped that patients will now receive the care that they require at an earlier stage and ultimately their length of hospital stay will be reduced.

    -  In terms of Social Services, the Discharge Delay Survey highlighted several problems that were affecting the discharge process. To deal with these problems, the Trust has formalised links with Social Services, with the result that there is a greater appreciation of the problems facing both organisations and a joint approach to dealing with the specific issues surrounding the management of emergency admissions.

4.2  Management of Emergency Admissions: 1997-98

  In terms of managing emergency admissions over the forthcoming months, there is to be further development in terms of the initiatives described above and additional, short-term, contingency plans to cope with the Winter pressures:

    -  The Bed Management Centre, wich currently operates 0800-2100 hours a day, is to be extended to provide a 24-hour service. This development will further stream-line the process by which emergency cases are admitted and provide the Trust with a fully comprehensive bed management system. There will be costs associated with this.

    -  As the Discharge Coordinator pilot scheme becomes more effective, these posts will be made substantive and consideration is to be given to increasing the number of staff in such posts.

    -  On completion and agreement of the new Discharge Policy, there is to be widespread training of all staff involved in discharge planning.

    -  Although "discharge lounges" are available within the Trust, they are not being used to their full potential. These are comfortable areas, staffed by a nursing auxiliary, away from the busy wards, where patients who have been discharged, can go to wait for their transport home. Work is therefore being undertaken to improve the standard of these facilities and to educate staff in their use.

    -  During peaks in emergency admissions, the Trust is planning to expand the bed resource by opening beds that are currently unused. We have two empty wards in the hospital that have been used in recent years for wards to move into whilst fire precaution work was being undertaken. These wards are now set aside to house the wards from the CRI when they move to the UHW in early 1999, the beds can be used in the short term though for emergency admissions.The viability of this plan is, however, dependent on the availability of nurses to staff the beds.

    -  The Trust, in conjunction with Social Services and the Health Authority are currently pursuing, as a pilot project, the use of nursing home beds as an additional bed resource. These beds will be used to accommodate patients, who are medically fit for discharge, but whose discharge is being delayed because of Local Authority funding issues.

5.  THE NEW MONEY IN WALES

  In addition to the above plans and in response to the Welsh Office allocation of funds to deal with emergency admissions, the Trust has put forward to the Health Authority, a number of other projects/developments which could help in the management of emergency admissions this winter. In summary our proposals are:

    -  Opening additional beds

    -  Appointing additional Discharge Coordinators

    -  Developing the discharge lounges

    -  Extending the dedicated Ambulance facility

    -  Extending the out of hours Bed Management Service

    -  Extending the Pathology Services to speed up testing

    -  Increase the Radiology Service to reduce waits for X-rays

    -  Develop a Day Procedure facility for patients not needing to stay

    -  Increase the Therapist input to Rehabilitation

    -  Appoint a Staff Grade Doctor to receive patients

    -  Extend the portering service to speed up Specimen collection and results reporting

    -  Appoint a Designated Social Worker to speed up assessments

    -  Appoint additional staff in the Admissions Unit

    -  Provide funds to care for people in the community or in alternative settings

    -  Develop a Medical Assessment Ward

  Our total bid for these initiatives to Bro Taf was £594,300.

5.1  Our Spending Plans

  We have been allocated £300,000 from Bro Taf to invest in a range of the schemes described. We will be implementing those schemes which are quick to do and will have most impact. There is inevitably a difficulty with the timing of the initiative, since we will need to recruit and train staff in new roles which will take some time to happen. Furthermore, since the money only lasts until April, the appointments will all be short term, making recruitment difficult. If the initiative is repeated in future years, we would benefit from an earlier decision on funding to enable us to have schemes up and running by December, and the ability to continue to fund the successful schemes on an ongoing basis.

5.2  Assessing the Outcome of these Initiatives-Value for Money

  There is clearly a need for a baseline to measure the outcomes of these initiatives. A baseline already exists to measure the number of people entering hospital and how long they stay. However, measuring the outcome of the work aimed at preventing admission will be difficult. More work will be needed on this for the future and a mathematical modelling approach may be appropriate. It is important that an evaluation is carried out after this winter to learn the lessons for next year.

5.3  Nurse Recruitment Difficulties

  Many of our plans rely on us being able to open more beds. We have already recognised the difficulty in doing this because of the shortage of nurses, indeed some of our beds are already closed because we cannot recruit qualified nurses. This is a difficulty across Wales and is something we are actively working with the School of Nursing to overcome, but the problem will exist for the foreseeable future. The reasons for the shortage are well documented with high drop out rates from nurse training; the colleges not always recruiting their full quota of students; poor workforce planning in the past; and a high percentage of newly qualified staff leaving Wales for employment elsewhere.

6.  OUR PLANS FOR EMERGENCY ADMISSIONS IN THE FUTURE

6.1  Developing Partnerships

  In terms of future plans, the Trust considers its relationship with the Health Authority, Social Services, the Primary Health Care Team and Voluntary Agencies as essential to the efficient management of emergency admissions and also to prevent future admissions. It is, therefore, envisaged that long-term plans will involve building partnerships with these agencies and developing joint projects that will:

    (a)  Reduce the need for patients to be admitted to hospital (manage demand).

    (b)  Ensure that there is adequate provision for patients on discharge from hospital.

6.2  The Emergency Stream Project

  The Trust Board has agreed to commence a major project to improve the quality and effectiveness of our services for emergency patients. This project is chaired by one of our non-executive Directors and involves the Medical Director together with a new appointment of Associate Medical Director specifically for this project. The project will involve examining the flow of patients through the process of admission, stay and discharge. Through this work we aim to deliver change to improve the services.

  Improving the provision of our emergency services is essential for the future clinical and financial viability of the Trust. Our plan is to improve the quality of our services to our patients by doing things better and faster, such as getting test results back quickly, enabling earlier diagnosis and treatment. This in turn will give us opportunities to further develop our clinical services, allowing us to maximise the use of our resources whilst offering a more responsive and effective emergency care service.

6.3  The Transfer of the A&E Department to UHW

  The transfer of the services from the CRI to UHW in 1999 gives us a tremendous opportunity to change and improve the care we offer to our patients. We have been working on this project for 2 years. The combination of services onto one site will allow us to improve efficiency and provide a better service all round.

  A Project Group involving Doctors and Nurses has been working on the clinical implictions for the Trust of the transfer of services from CRI. Their work has focused on the emergency patients entering the Trust via GP referrals and through A&E. This has involved mapping patient flow prior to arrival, in A&E and looking at how this can be done differently and better in future. The new facilities will include a new 25 station Assessment Unit and we are working on a new treatment protocols and rapid access to tests and investigations together with improved communication with General Practitioners and availability of alternatives to admission for some patients.

  The Project Group's report will be discussed with a wider group of clinical specialities early in 1998 and plans will then be developed and implemented in conjunction with the Emergency Stream Review.

7.  SUMMARY AND CONCLUSIONS

    -  Emergency admissions should be considered in the wider context of all the changes being made in the Health Service in Wales, and not considered in isolation.

    -  There are well documented reasons for the rise in emergency admissions and whilst the percentages may look low, the impact on Trusts is immense with people staying longer in the winter months because they are often more poorly.

    -  The impact on the UHW as a Teaching Hospital is different to a District General Hospital, with cases being more complex and the need for us to maintain the teaching and research even during the busy periods.

    -  The targets for Trusts are incompatible and need to be clearly prioritised by the Welsh Office. Dealing with emergencies can mean our waiting lists rise and if we deal with all emergencies, we may not be in a position to balance the books.

    -  Collaboration and cooperation within Cardiff is essential for an effective service and one acute Trust in Cardiff would resolve many issues relating to emergency admissions.

    -  The UHW has done much to manage the rise in emergencies and has never closed its doors. We have plans for the future including a major project to improve the overall effectiveness of the way we deal with emergency admissions.

    -  Collaboration with Social Services, Primary Care and Voluntary Organisations is vital for the future to put in place measures to prevent unnecessary admissions and to speed up the process of discharging patients.

    -  The new money in Wales is very welcome and we will be implementing a range of schemes.

    -  Nurse recruitment difficulties will be a factor this winter.

    -  It is important that a review is conducted to learn the lessons for next year.

Allister Stewart,
Chief Executive
12 December 1997


 
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