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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