London A&Es brace for their worst winter crisis

Ross Lydall @RossLydall23 December 2015

The extraordinary pressure on London A&Es can be revealed today. Hospital bosses fear 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 £650 million Royal London — one of four major trauma centres — 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 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.”

Last January Croydon was forced to declare an “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, which every month provides rapid treatment to almost 2,000 patients 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 decisions — something not always possible via the traditional A&E route,” he added.

Croydon hit the four-hour target last month and in December’s first week.

St Helier, in Carshalton, 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 clear the way for more time to be spent on sicker patients, said emergency department clinical director Amir Hassan.

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 2014, 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 a Monday earlier this month, bosses decided to keep the urgent care centre open until midnight for the rest of the winter to prevent flooding the main A&E department with “minor” patients and breaching the four-hour target when it closed at 10pm.

Ms Sullivan said: “We have 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 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 then goes twice 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 waiting 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 herald a frenetic day.

Claire Nash, Barnet’s general manager for patient flow, said: “We are the only part of the healthcare sector that can’t say ‘Stop’.”

Across the Royal Free’s three hospitals — at Hampstead, Chase Farm and Barnet — up to 100 patients a day are fit 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 other hospitals reach crisis levels.

Ms Slemeck said: “If Northwick Park and Watford General are not coping with the pressure, ambulance services start diverting away and bringing us more work. There is a risk of that toppling us over.”

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 people dying.

“I can ring my GP with my big toe problem and they’ll see you next week,” he said. “But I can walk into A&E and know I have to be sorted within four hours.

“The four-hour target needs to be thought through and refined. If you have to wait eight hours, so what? You aren’t going to die. If you take away this target you will save a lot of money and maybe re-educate the population.”

Barbara Levy, 63, was rushed to A&E at 3am from her home in Mill Hill after a suspected heart attack. “It was excruciating,” she told the Standard. Doctors admitted her to a cardiology ward for further tests.

SHE said her care was “excellent, though it could be faster”.

But she doubts the diagnosis, believing she merely had indigestion from eating chestnuts. “I think I just overdid it,” she said. Emergency matron Loraine Chowdry sympathised: “The most comfortable bed is the one at home.”

Dr Andy Mitchell, medical director of NHS England (London), said the capital was better prepared to cope with winter than he had ever known. He urged Londoners to get the flu vaccine and to use the NHS 111 non-emergency helpline and pharmacies rather than A&E.

“Where hospital care is necessary, we will ensure the sickest patients have priority,” he said. “It 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.”

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