With demand on health and social care services translating into increasing pressure on emergency departments, staff are going to extraordinary lengths to mitigate risks to patient safety. However, while many hospitals continued to provide safe high quality services over the winter, there has been an impact on both patients and staff. New ways of collaborating and planning across the whole health and social care system are needed now to ensure that next winter is different.
In a report published today (Thursday 24 May) the Care Quality Commission presents the findings from CQC’s inspections of emergency departments over winter 17/18 alongside the findings of workshops attended by over 70 frontline clinicians aimed at understanding the issues facing staff and what needs to change.
‘Under pressure: safely managing increased demand in emergency departments’ features practical solutions from frontline staff that can be used to help maintain safe services when faced with surges in demand, but also calls for wider action by the whole health and care system to ensure a joint approach to managing the capacity problem as demand continues to grow. The solutions focus on action that can be taken to help keep people well and reduce emergency department attendances, steps that emergency departments can take to better manage the flow of patients through the hospital, and ways to help avoid unnecessary admissions and ensure early discharge.
Professor Ted Baker, Chief Inspector of Hospitals at the Care Quality Commission, said: “During an unprecedentedly challenging winter, we have seen staff going above and beyond to deliver safe care to patients - their commitment and efforts in such difficult circumstances must be commended.
“Our inspections of urgent and emergency services have found evidence of good practice and of individual providers that have been able to make improvements. However, we have also found too much variation and we have seen how increased pressure has led to some patients receiving care that is wholly unsatisfactory.
“So that we can understand the issues facing emergency departments and can support improvements, we have worked with frontline staff from hospitals across the country to help understand barriers and support change. These discussions have generated a number of practical suggestions that we’ve shared in this report, with examples of where they have been effectively applied, that can be used by others to help maintain safe, high quality care in the face of operational pressures.
“But these practical suggestions are only part of the answer. Hospitals cannot work alone to address the ever increasing demand on services - there has to be a system wide approach with all parts of the health and social care system working together to find solutions. We cannot accept that each winter will be worse than the one before – we are already seeing the impact on both patients and staff. It is clear that what used to work doesn’t work anymore - new ways of collaborating and planning for surges in demand need to happen now to ensure that next winter is different.”
The report shows that CQC inspections have found evidence of good practice at a number of emergency departments and individual examples of hospitals that have been better able to plan for and manage increased patient attendances. However, the quality and safety of urgent and emergency care remains a concern with 50% of urgent and emergency services rated as requires improvement or inadequate overall and 8% of services rated inadequate for safety.
CQC inspections have found specific concerns around delayed ambulance handovers and people waiting for long periods of time before their first clinical assessment, with patients needing urgent care not always being identified in a timely way. While escalation policies were generally in place, they were not consistently followed or were not effective in coping with increased demand. A further concern was the use of inappropriate spaces - such as corridors - for patient care. CQC found that many hospitals were caring for patients in such spaces routinely, with no plans in place for alternative safer accommodation.
Looking beyond hospital emergency departments, the findings from CQC’s local system reviews show a variation in the way that in the way that local systems have worked together to prepare for surges in demand. These Government-commissioned reviews of 20 local areas are exploring how well local health and social care systems work together to support and care for people aged 65 and over, including the interplay between emergency care provision and other local services.
Although in some cases CQC has seen good examples of systems working collaboratively to plan for winter pressures, the reviews have raised concerns about the timeliness of this planning and the extent to which all partners across the system are involved in the planning process, with independent social care providers and voluntary, community and social enterprise organisations often less engaged.
While a whole system approach is needed to tackle the problems created by increasing demand, the discussions at CQC workshops held with over 70 frontline clinicians have generated a number of practical solutions to help mitigate risks to patient safety in pressured emergency departments. The solutions are presented alongside examples of good practice in action at hospitals across the country which builds on the best practice guide published by CQC in November 2017.