WINTER PRESSURES IN THE SUMMER?

This summer, A&Es (Emergency Departments or EDs) have experienced record high attendances and the worst ever 4-hour performance. Alongside this, covid-19 hospitalisations remain fairly low, which raises the question – why are EDs experiencing winter pressures during summer?

Primary Care

The pandemic has altered access to many healthcare services. General Practice and mental health services are under-resourced, with many GPs and services moving to offer more ‘virtual’ services, which may not always be appropriate and create barriers to treatment, particularly for those with more serious issues. 90% of GPs feel they can deliver the best health outcomes all or most of the time through face-to-face consultations, compared to only 75% over the phone and 46% via video. 1 A small deterioration in people accessing appropriate consultations puts great pressure on EDs. For mental health, limited community support, alongside fewer hospital beds, has led to significant unmet need, particularly as mental illnesses have risen because of lockdowns. EDs have become a ‘first contact’ for people in mental health crises due to a lack of alternatives.2

NHS 111

The purpose of NHS 111 is to give advice and direct patients towards the most appropriate healthcare services, limiting demand in EDs. Calls have increased considerably recently: May 2021 saw the largest number of calls ever received and 12% of triaged calls were streamed towards EDs. Prior to the pandemic, this percentage nearly always remained under 10%. While this increase may not seem significant, it translates to over 100,000 more recommendations between April 2020 and May 2021. In our recent workforce survey, an overwhelming 50.7% of clinicians responded that phone-first services had increased or significantly increased demand in their ED. NHS 111 is currently not fulfilling its purpose. These services are only effective when there is adequate clinical involvement to accurately assess patients’ needs, and alternate services on offer for patients to go to.

Elective Backlog

We have a staggering 5.45 million people on the elective surgery waiting list. 6 million fewer people were referred into consultant-led elective care in 2020 compared to 2019.3 People are experiencing complications relating to delayed procedures and those who avoided accessing healthcare are now attending EDs with more serious issues. If we want to effectively tackle the elective backlog, we must effectively manage emergency demand. Every winter, elective surgeries are cancelled due to rising emergency admissions. As we are already experiencing winter levels of demand, the elective backlog could be further derailed.

Young people

Easing restrictions have resulted in high numbers of children acquiring infections usually seen in winter. Many parents are taking a risk adverse approach and bringing young children with mild fevers to A&E rather than seeking help elsewhere. Partnered with difficulty in accessing other services, this has led to a spike in attendances.

Looking forward...

Throughout the pandemic, NHS staff have shown their resilience. However, this way of working is not sustainable and has increased rates of burnout.4 EDs have a diminished ability to handle increases in demand due to fewer hospital beds and social distancing measures. When demand rises, patients can experience care in unsafe conditions. There is a need for a new approach: expansion is required across the whole healthcare system to ensure it is fit to provide all patients the right care at the right time.

College of General Practitioners (2021). https://www.rcgp.org.uk/about-us/ news/2021/may/gp-consultations-post-covid.aspx

Quality Commission (2020). https://www.cqc.org.uk/news/releases/cqc-findsmental-health-inpatient-services-coped-well-coronavirus-covid-19-there-will

Health Foundation (2021). https://www.health.org.uk/news-and-comment/charts-andinfographics/how-is-elective-care-coping-with-the-continuing-impact-of-covid-19

College of Emergency Medicine (2021). https://www.rcem.ac.uk/docs/Policy/ Retain%20Recruit%20Recover%20-%20Our%20Call%20for%20Action%20to%20 Improve%20the%20Urgent%20and%20Emergency%20Care%20System.pdf