On December 9 2019, while campaigning in Grimsby, Prime Minister Boris Johnson repeatedly declined to see a phone image which ITV Political Correspondent Joe Pike was attempting to show him. He then took the reporter’s phone and placed it in his own waistcoat pocket, only to finally view the image on further prompting. The image was that of four-year-old Jack Williment-Barr, who was lying on the floor of a treatment room in the emergency department at Leeds General Infirmary, on December 4. At that time, he had “suspected pneumonia”, and had been provided with an oxygen mask. Jack was on the floor as there was no free trolley, not even a chair, available in the department at the time.
Jack’s predicament, tragic and unacceptable as it was, once again fed into a continuing narrative of an under-resourced NHS, desperately in need of increased funding. Crowding in emergency departments is, however, a global problem, and highlights structural issues with the provision of emergency care in a wide range of different communities and healthcare services, irrespective of actual levels of funding.
There is no standard universally agreed definition of a crowded emergency department. According to the ACEP (American College of Emergency Physicians) Crowding Resources Task Force, emergency department crowding is “a situation in which the identified need for emergency services outstrips available resources in the emergency department”. However, it isn’t simply a matter of insufficient emergency department resources. Large and steadily increasing numbers of people are stacking up in emergency departments because a lack of resources elsewhere in the hospital (available on-call staff; ward and intensive care beds) as well as within the community (available general practitioners, community nurses and therapists).
Crowded emergency departments have come to be accepted as an inevitable part of healthcare services that are struggling to cope. Busy inner- city departments are frequently been likened to “urban war zones”. The immediate effects of a lack of space include long waits for initial triage assessment, crowded waiting rooms, queues of ambulances outside, people on trolleys and chairs lining corridors and hallways, long delays to diagnosis and treatment, and an increased risk of errors of all kinds. Privacy and dignity are frequently compromised in such a situation. Some particularly vulnerable people may even choose to leave without actually being seen. Staff in departments that are frequently crowded may suffer from low morale and burnout, further impairing their performance at work. Long waiting times are a major source of complaints against emergency departments, as well as providing ammunition for whatever political parties happen to be in opposition at any given time.
The four-hour target for seeing, treating and discharging 95 per cent of people within four hours of their arrival in the emergency department has not met been met for several years by the NHS in England. Many of the initiatives that have been introduced over the years to maintain these targets previously were already running at maximum possible efficiency before being overwhelmed by an ever-increasing workload (24.8 million attendances at emergency departments in England in 2018-19).
Throughput of people within the emergency department can be speeded up by increasing the numbers of available nurses and doctors, given that there are widespread shortages of emergency staff, which often increases individual workloads to an unsafe level. But this only works up to a point. Once a department runs out of space and comes to a standstill, staff may find themselves unoccupied as they vie for a place to see the next patient in.
Rapid initial assessment at the first point of contact, often in specially designated areas, can mean that people are suitably assessed, prioritised, given essential treatments like pain relief, fluids, antibiotics and “clot-busting” drugs, and even “fast tracked” to appropriate care providers-such as those with heart attacks, strokes and fractured hips. In addition, blood tests, X-rays, ultrasound and CT scans can be requested to facilitate early decision making. Some people can be sent directly to observation units, assessment areas, and even to specialist clinics or inpatient wards. Such processes can be further speeded up when the system is overloaded. “Overcapacity protocols” in overwhelmed hospitals thus make use of processes and protocols normally used to deal with major incidents.
An emergency department may run efficiently and have robust processes in place but still under-perform when it comes to meeting targets. This is the result of a continuing arrival of new patients into an already clogged-up department. This mismatch of demand and supply is further exacerbated by a failure of output of patients awaiting admission to hospital. An access or exit block arises when there are no immediately available inpatient beds, which is not infrequent when hospitals are already running at capacities approaching 100 per cent.
The input to emergency departments has been steadily rising. Many groups of people, including the elderly, those with chronic illness, mental health problems, substance abuse disorders, and unmet social needs are often better dealt with in the community. Some people attend emergency departments with non-urgent problems as they have nowhere else to go. NHS 111, an online service staffed by trained lay call handlers and nurses, may also direct such people to the emergency department by a process of default, guided by algorithms. Unfortunately, access to primary care, in the form of available slots to see a GP, reductions in home visits to the housebound, and reduced community nursing and therapy services, has been declining in recent years. This shortfall has only partly been met with by the opening of walk-in urgent care centres.
It is quite clear that the crowding of emergency departments is a multi-factorial problem, which requires many simultaneous solutions. These solutions involve better resourcing of primary, secondary (general hospital) and tertiary (specialist hospital) care services. There are no quick fixes for a widespread and systemic problem of such complexity, no matter what politicians may promise. While rhetoric focused on increased funding for the NHS resonates with the public, yet again the wider question of what the NHS can and should provide and how this is achieved is out in the open. In the meantime, news stories such as that of Jack are likely to continue to feature in the media and encourage public debate or, more likely, public mudslinging.
Ashis Banerjee (retired Consultant in Emergency Medicine, London)