John had tried to hold on as long as he could. The cough had started on Christmas Day; he had hoped to be able to see his own GP on Monday but by the Sunday of the 4 day holiday his breathing was becoming a real struggle. He’d had chest infections before – ever since his stroke 3 years ago he had been prone to this, but his GP usually managed to keep him out of hospital. The stroke had left John with a significant left sided weakness, but with the assistance of twice daily carers he got by. John didn’t want to go into hospital, but the doctor from the out of hours service convinced him that it was the best option; the combination of a significantly reduced oxygen saturation, low blood pressure and a tachycardia left him with little alternative. ‘The hospital will patch you up and have you out in no time’, he promised.
Intravenous antibiotics and fluids were started swiftly on his arrival in the emergency department’s resuscitation room – a chest x-ray confirmed lobar pneumonia and within 48 hours he was starting to feel better; by New Year’s day he was back on oral antibiotics and starting to mobilise with assistance from the physio. By the following Sunday – a week after admission – he was deemed to be ‘back to baseline’ – able to be discharged, as soon as his ‘package of care’ could be restarted. 30 minutes in the morning and 15 minutes at lunchtime was all he would require – hopefully this would just take a phone-call…
But of course nothing is ever that simple. John’s carers had been reallocated to other clients following his hospital admission; re-establishing his care package would take some time and there was already a backlog of other patients which had built up over the Christmas period. A week, at least, would be required in order to get things re-started. In the meantime he would have to wait. In his hospital bed.
This week I have stepped outside my usual ‘comfort zone’ of the Acute Medical Unit, to lead a general medical team on the wards in our hospital. My patients have been those who don’t fit into a clear-cut speciality category and who are not old enough to require the skills of a geriatrician. Patients like John.
Meanwhile, acute and emergency medicine have been in the spotlight – most hospitals have been on ‘black alert’ and many have declared major incidents. A large influx of patients with acute respiratory illness has left Emergency Departments struggling to cope; figures released by the Department of Health have confirmed that the proportion of patients waiting over 4 hours prior to discharge or transfer from the ED has risen dramatically. Queues of patients on trolleys and ambulances lined up on the hospital forecourt have become a common sight; the ‘A&E crisis’ has barely been out of the news.
But there is another story, which is not being told. The story of patients like John, and many thousands of others like him, waiting in hospital beds across the UK; no longer unwell, but unable to leave hospital until social care can be arranged. For some, the needs are complex: patients can wait for a number of weeks for funding to be arranged or a new care placement to be found. However, even those whose care needs are already well established are experiencing delays.
This is not a new problem – we have been talking about ‘delayed discharges’ for at least 20 years, and January is always a particular challenge after the Christmas break. However this year undoubtedly feels worse than ever. Much worse. Health care funding has been ring fenced by the government, while social care funding has been subject to significant cuts. It is not hard to understand why the problem has arisen. Furthermore, there is no slack in the social care system – when a patient goes into hospital the carers cannot sit back and wait for them to be discharged; there is always someone else who needs help. Everyone needs to be prioritised, and a patient whose care needs are being met in a hospital bed inevitably slips down the priority list. In the meantime, ‘health’ is picking up the bill and our hospital beds are all full.
The solution to the current ‘A&E crisis’ will not be found in the A&E department itself. It will not be found by telling patients to ‘stay away’. The majority of those waiting for long periods in our A&E corridors are unwell and require an in-patient bed: to solve this problem we must look further downstream. It is time to re-focus our attention on the cause of the crisis, not the symptom. If we want to unblock A&E we must unblock the hospital.
Thankfully John’s hospital stay was shorter than was initially anticipated – on this occasion our discharge facilitation team worked some magic and by the middle of the week he was on his way home. There will many others in hospital beds across the UK tonight, and for many nights to come, who will not be so lucky…..
John gave his consent for has case to be shared; his name and some clinical details have been changed to protect his anonymity
G Purdie said:
Couldn’t agree more.
An additional problem is that of ‘nursing home’ placements. As these are predominantly private sector organisations, they have no obligation to take any single patient. Therefore for a particularly ‘care intensive’ patient (eg a bariatric person) it often takes assessments by numerous homes before one can be found to accept them.