Consultants have ‘phenomenal impact’ on A&E demand, report suggests

A new paper published by the Institute of Healthcare Management (IHM), The Winter’s Tale, has given a snapshot of 2016/7 winter pressures through the undiluted voices of NHS managers and clinicians.

A series of in-depth interviews undertaken by the IHM with trusts across England revealed a disparity in hospitals’ ability to cope with pressures that were described as ‘challenging’. One department reported periods of two or three hours when a patient was arriving every 90 seconds, while recent official figures show there was a 45 per cent increase on people waiting more than four hours after a decision to admit. 

The Winter’s Tale showed there is clear evidence to support the fact that, where professional managers and clinical leaders are working closely and collaboratively, and where senior clinicians are hands-on ‘at the front door’ of A&E, there is a ‘phenomenal impact’ on demand, at the same time alleviating pressures on staff without compromise to patient outcome. The paper reports that when consultants are present in A&E, the replication of work is reduced. The traditional pathway is that a patient is seen by a nurse, then seen by a junior doctor, then seen by a registrar, and only then by a consultant. When a consultant makes an immediate assessment, he or she is in a position to admit a patient or suggest an alternative.

One London trust which adopted this approach is now sending 60 to 70 adults a day – about 30 per cent of patients who take themselves to A&E – back into the community. On average, consultants take four minutes or so to reassure patients that they are safe to go home. Had they been seen them in the same way as they were in 2015/16, each patient consultation would have taken 20 to 30 minutes. The report indicates there is a very good evidence base to show that that a high percentage of people did not in fact make a GP appointment, even though recommended to do so.

Echoing this, the report recognises that when putting consultants close to the front door, further pressures can be reduced through the increased use of pharmacists, paramedics, nurses, occupational therapists, physiotherapists and social workers. The paper describes an approach in one trust where frail patients arrive in A&E and rather than being passed around the system before ending up on a ward where everything from mobility to continence management can be compromised, therapists and social workers wrap around them as soon as they enter the hospital, with the intention of getting them back to their own homes as quickly as possible.

Jill de Bene, chief executive of the IHM, said: “We wanted to understand what winter pressures felt like, directly from people working on the front line: The Winter’s Tale provides an unsurprising patchwork of stories that reveal the good, the bad and the unacceptable. From nurses experiencing chest pains to shining examples of brave thinking and actions that are making profound and positive differences to emergency departments across the country. Transformational change is possible, even in the most challenging of times, through strong, effective management and collaborative working.

“When experienced staff see the patient first and make the big judgment calls, the positive impact for everyone involved is unquestionable. You need someone in A&E who has the clinical confidence to say no to someone whose problem should be dealt with elsewhere in the system.

 “And you need a management perspective that takes into account a deeper understanding of the hospital and wider-system – someone who understands the domino effect of admitting a patient who could be better supported elsewhere in the system, and someone who understands the value of having the right person in the right place, regardless of their discipline. What we’ve learnt is that A&E is largely seen by others in the hospital as a problematic island, whereas it’s actually an intrinsic part of the wider ocean – it’s a challenge that belongs to everyone in the system.”

de Bene concluded: “Every department that has improved performance has done so on the back of transforming the relationship between consultants and managers. While there is unquestionable room for improvement, we have learnt that effective, values-led management, with a strong culture of joined-up learning and working can make a tangible difference in managing extreme pressure. Our immediate challenge is to share this as widely as possible to help hospitals still struggling to deal with what feels like unmanageable demand.”