RCEM: We have a serious problem in Urgent & Emergency Care

Emergency Department performance figures published by NHS England for June 2021 show the highest number of Type 1 attendances ever recorded, the worst four-hour performance for the month of June, and the highest ever number of total emergency admissions for the month of June.

The data show that in June 2021 1,436,613 patients attended Type 1 Emergency Departments, the highest ever figure since records began.

A total of 400,826 patients were admitted via Type 1 Emergency Departments, the highest ever recorded figure for the month of June.

Four-hour performance in Type 1 departments was 73.2% which is by far the lowest June percentage on record.

1,289 patients were delayed by 12-hours or more in an Emergency Department – almost double the figure of the previous month. It is also the highest ever recorded figure for the month of June, and almost triple the previous highest figure for June recorded in 2019.

Dr Katherine Henderson, President of the Royal College of Emergency Medicine, said: “We have a serious problem in urgent and emergency care. We are deeply concerned. We are facing record breaking figures in the high summer. We can only begin to imagine what this winter may bring.

“We are facing record breaking attendances with a tired workforce and fewer beds; it is seriously challenging. Busy departments are a threat to patient safety, it increases the chance of crowding and corridor care, this risk is significantly increased if covid and non-covid patients are sharing the space for long periods of time.

“We ask that there is a transparent discussion about how the whole of the health service deals with the current levels of demand. Emergency care does not happen in a vacuum but is often the canary of the system. Managing demand in Primary care, the elective backlog and what is happening at the front doors of hospitals is all connected and there is urgent need for a plan that balances these needs in a way everyone can understand.

“The data show what is happening on the ground, and it is likely that things will worsen in the coming months, especially as we enter the winter. The government must realize there is a looming crisis and take swift and urgent action – this is critical ahead of Winter.

“Hospitals can only do all they can to boost capacity, in the face of serious resourcing constraints. And we would ask patients to only attend Emergency Department if they need urgent and emergency care, and seek alternative care, like from their GP or NHS 111, if they have a minor injury or mild condition.

“Despite now being in the middle of summer, our Summer to Recover: Winter-Proofing Urgent and Emergency Care for 2021 contains the necessary actions the government and the NHS can take ahead of Winter.

“If no action is taken, we may soon be in the middle of a crisis worse than any previous winter.”

Edinburgh Park mass vaccination centre welcomes final patients

Edinburgh Park’s mass vaccination centre will welcome its final patients this weekend as the site prepares for closure on Sunday.

The mass vaccination centre, based within the Royal Bank of Scotland’s former Younger Building, will close this weekend, having seen thousands of patients come through its doors.

Over the last four months, since the site opened on Monday 1 March, the vaccination team has administered 82,595 doses of the lifesaving vaccine.

NHS Lothian is now in the process of moving to a more flexible delivery model and will utilise more mobile and surge vaccination clinics.  This will allow the board to target people who are still to receive their jab by making it as easy as possible to be vaccinated.

The decommissioning of the site will begin on Monday (12 July). Those in the west Edinburgh area wishing to visit a drop-in clinic at a mass vaccination centre can do so at the Royal Highland Showground.

Airport buses have been temporarily diverted to allow passengers to be dropped off directly outside Lowland Hall.

The Edinburgh Park site will still welcome both appointments and drop-ins until closure.

Pat Wynne, Nurse Director of Primary and Community Care, NHS Lothian, said: “The site at RBS has played a key role in the vaccination programme so far and we are really thankful to our team who made it work so well. I would also say thank you to Royal Bank of Scotland for cooperation throughout the site’s operation.

“Anyone wishing to be vaccinated from Monday can do so visiting one of our four mass vaccination drop-in clinics across the region, which are continuing to operate.

“This weekend (10 and 11 July), we will be running our mobile vaccination clinics with the Scottish Ambulance Service at The Centre, Livingston (Sat), and Fort Kinnaird Shopping Centre (Sun).

“These are open to everyone over the age of 18 for first vaccination, and for those who are due their second vaccination having waited eight weeks.”

Do not ease COVID restrictions, warn doctors

The British Medical Association (BMA) has urged the UK Government this week to rethink its plan to relax all restrictions owing to the surge in COVID-19 infection rates. 

The association has been a leading voice in the debate on the issue on the national and international media.

Senior BMA members including chair of council Chaand Nagpaul and co-chairs of the BMA’s public health committee Penelope Toff and Richard Jarvis co-signed a letter in The Lancet published on Thursday – which described the easing of restrictions as ‘reckless’. 

Dr Nagpaul also appeared on the BBC’s Newsnight last night (9 July) saying it was ‘folly’ for the UK Government to press ahead with easing all restrictions on 19 July. He pointed to the growing evidence of spiralling infections leading to growing hospitalisations as well as wider effects on public health.

‘We need to dispel the idea we’ve broken the link with hospitalisations. It’s diluted but we have about three times as many people on ventilators than this time last month and two and a half times more people in hospital than last month,’ he said and added that if the trends continue this will further increase the pressures on the NHS. 

Dr Nagpaul added that this was not simply a secondary care issue but there were now growing numbers of the population suffering from the condition not going to hospital many of whom will go on to have long COVID.  

Chaand Nagpaul

The BMA is arguing for the UK Government to maintain some targeted control measure in place after 19 July including the requirement to continue wearing face coverings in indoor public settings and improved messaging on social distancing and meeting outdoors where possible. 

Dr Nagpaul (above) said full easing on the timescale proposed ‘defied public health logic’ – further unlocking of restrictions was a matter of timings rather than ‘indefinite restrictions’. Dr Nagpaul also appeared on CNN on Thursday arguing for targeted restrictions to remain. 

Following Monday’s press conference by the prime minister, the chief medical officer and the chief scientific adviser,  the BMA issued a statement describing the proposed easing of restriction as ‘incredibly concerning’.

‘There is a clear disconnect with the actions the Government is planning to take and the data and views of the scientific community and medical profession,’ it says.

On Monday evening deputy council chair David Wrigley appeared on Channel 5 News  to reflect on the announcement and said getting rid of restrictions was ‘reckless’ and was a ‘recipe for seeing an increase in infections which is not good for the NHS and not good for patients’. 

The BMA believes targeted measures and support are needed beyond 19 July 

The situation in Scotland remains concerning, where Covid levels are among the highest in Europe and hospitals are coming under increasing pressure.

The Scottish Cabinet meets on Tuesday morning and First Minister Nicola Sturgeon will update Holyrood on Scotland’s plans for moving to Level 0 on Tuesday afternoon.

The Scottish Government had originally planned that all parts of Scotland woud be in level zero from 19 July, allowing some additional relaxation to rules on physical distancing and outdoor gatherings.

Following these initial easings in July, the plan is that more restrictions will be removed on 9 August, including lifting the legal requirement to physically distance indoors.

However the Scottish Government has repeatedly said it will be driven by ‘data not dates’ and First Minister Nicola Sturgeon said earlier this week that these dates are not written in ‘tablets of stone’.

More staff to bolster Scotland’s Test and Protect system

Changes are working, insists Health Secretary

Scotland’s Test and Protect contact tracing system will see its workforce bolstered with the deployment of additional staff over the coming week to help address a rising number of coronavirus (COVID-19) cases.

Health Secretary Humza Yousaf  said recent changes to the system are helping its performance and the way it operates will continue to evolve as vaccination levels rise.

Ascensos, one of Test and Protect’s existing commercial partners, has agreed an arrangement with Barrhead Travel to accelerate and augment the capacity they are providing to the contact tracing system by 100 staff. Additional contact tracing bank staff continue to be brought on board and existing bank staff mobilised. 

Recent changes to the system have also been implemented aimed at ensuring a growing number of cases are closed by contact tracers and that high risk cases are prioritised. These include greater use of text messaging to contact lower risk index cases and digital self-tracing forms.

Mr Yousaf said: “Our Test and Protect workforce have played a vital role in the battle against this pandemic. We  owe these contact tracing teams a huge debt of gratitude for all their efforts over the past year.

“The Test and Protect system has continued to operate well as case numbers have increased in recent weeks, contacting unprecedented numbers of people.

“This agreement to bring in additional staff follows our ongoing efforts this year to ensure commercial partners were on board in preparation  for potential increases in demand on the contact tracing system.

“This extra workforce is important, but the  success of the system going forward will not simply be about staffing numbers. 

“Test and Protect will  change as the population becomes more protected by vaccination and it will still play a key role in mitigating clusters and outbreaks in high risk settings, slowing infection spread and protecting populations at risk.

“As we announced last week, we are now using a variety of methods to contact people, including using digital methods like SMS messages for lower risk cases and prioritising calls for higher risk cases. These changes, along with extra staffing, will ensure that people are contact traced, and begin self-isolation, as quickly as possible. I’m confident that the performance of Test and Protect has started to improve in recent days.

“The majority of people comply when asked to self-isolate and we are thankful for the important role they are continue to play in stopping transmission of COVID-19.

“We will have to manage living with COVID-19 for some time to come, even when we are able to move beyond Level 0. While we hope we are in the process of emerging from the pandemic, case rates at the moment underline the fact that this virus is still with us.”

Recently announced measures have been implemented to streamline the contact tracing system to manage pressure on the system and ensure it is more efficient.

These include greater use of text messaging to contact lower risk index cases and digital self-tracing forms.

The new approach ensures that the contact tracing system is using its resource appropriately and proportionate to public health risks: Test and Protect to prioritise high risk cases – gov.scot (www.gov.scot)

Test and Protect is an NHS-led service which works with commercial partners to help augment capacity when required.

Contact tracing capacity in Scotland is split between the National Contact Centre operated by National Services Scotland (NSS) and  the daily contact tracing workforce  provided by territorial Health Boards.

All mainland health boards offer drop-in coronavirus (COVID-19) vaccination clinics: Drop-in vaccine clinics in every mainland health board – gov.scot (www.gov.scot)

Scotland’s Emergency Departments experience worst ever May performance

The latest data released yesterday by the Scottish Government for May 2021 show that attendances at Emergency Departments have risen significantly.

In May 2021 there were 112,563 attendances to major Emergency Departments across Scotland. This is a 12% increase compared to April 2021, a 24% increase when compared to March 2021, and a 45% increase compared to May 2020.

Following this increase, four-hour performance deteriorated, 86% of attendances to major Emergency Departments in Scotland were seen within four hours. 15,706 patients were delayed by four-hours or more in an Emergency Department, this is the highest figure since January 2020, and it is the highest figure ever recorded for the month of May. This means one in seven patients were delayed by four hours or more before being seen.

In May 2021, 393 patients spent 12 hours or more in an Emergency Department, this is double the figure for April 2021. This is the highest number of 12-hour delays for the month of May ever recorded, and it is more than double the previous highest May figure of 189 12-hour delays that was recorded in 2019.

Data also show that 1,680 patients spent eight hours or more in a major Emergency Department, this is an increase of nearly 50% compared to April 2021 and it is the highest figure ever recorded for the month of May.

Dr John Thomson, Vice President of the Royal College of Emergency Medicine, said: “The data is deeply concerning and very much reflects what is happening on the ground. Departments are busier than ever, especially for the summer period with some record-breaking figures for the month of May, and it is becoming increasingly challenging.

“These figures come at a time when reports suggest Scotland has the highest covid infection rate in Europe. We are battling community admissions, elective care patients seeking treatment, as well as increasing covid patients attending our departments, all within the context of reduced bed-stock.

“Departments are filled with patients, some who may have covid, waiting to be seen. While long-stays alone can put patient safety at risk. This risk is increased as some patients could contract the disease in a busy Emergency Department.

“The College’s recent Emergency Medicine workforce census in Scotland revealed an Emergency Medicine workforce that was not adequately staffed to deliver the highest quality patient care in Emergency Departments in Scotland.

We have shortages across the board, but particularly among consultants and senior decision-making clinicians. These shortages are currently exacerbated by the soaring covid infection rate, meaning there are a large number of absent NHS staff due to covid in Scotland.

“We are doing all we can to maintain flow and maximise patient safety, but the pressures are increasingly intense and are faced by the existing but short-staffed workforce that are facing continued burnout and exhaustion.

“The data show the growing demand for urgent and emergency care, Emergency Departments are where people turn to for treatment when there is nowhere else to go, so they must be adequately staffed with trained Emergency Medicine staff, properly funded, and equipped with enough capacity and resources to cope with severe demand.”

“We urgently need the Scottish Government to support the urgent and emergency care system to cope with these pressures.”

Two NHS Grampian hospitals have announced this week that they are at capacity as Covid cases rise.

Scotland was expected to move to level zero on 19 July, with remaining legal restrictions lifted on 9 August, but First Minister Nicola Sturgeon conceded yesterday that th planned dates are not “set in stone”.

She will be holding a media briefing at lunchtime today:

NHS Lothian given £27 million in extra COVID funding

NHS Lothian has been given £27 million in extra COVID-19 funding from the Scottish Government as part of a £380 million package allocated to health boards across Scotland.

This comes on top of the £1.7 billion already provided to health boards and Health and Social Care Partnerships last year.

The additional funding includes ongoing support for the vaccination programme, the Test and Protect system, and personal protective equipment for health and care workers.

SNP MSP for Edinburgh Pentlands, Gordon MacDonald MSP said: “NHS Lothian has been under incredible pressure during the pandemic, not only will this additional funding support the health board with its efforts to treat patients but it will also play a role in supporting our NHS in its remobilisation programme as we come out of the pandemic.

“It is essential that our health services can be on a sure footing as we re-emerge from the pandemic and other services that have been disrupted can restart smoothly.

“This is a demonstration again that the only party in Scotland that can protect Scotland’s NHS is the SNP.”

 Covid Funding (£m)
NHS Ayrshire and Arran                   13.7
NHS Borders                     3.4
NHS Dumfries and Galloway                     4.9
NHS Fife                   11.6
NHS Forth Valley                   10.1
NHS Grampian                   16.2
NHS Greater Glasgow and Clyde                   45.8
NHS Highland                     9.8
NHS Lanarkshire                   25.9
NHS Lothian                   27.0
NHS Orkney                     0.7
NHS Shetland                     0.7
NHS Tayside                   13.7
NHS Western Isles                     0.9
National Waiting Times Centre                     3.9
Scottish Ambulance Service                   17.4
The State Hospital                     0.3
NHS 24                     2.7
NHS Education for Scotland                     1.8
NHS National Services Scotland                156.3
Healthcare Improvement Scotland                     0.4
Public Health Scotland                   12.6
Total                379.6

Emergency! Key staff shortages are increasing the pressure on struggling ED workforce

Census by RCEM Scotland shows a shortage of key senior decision-making clinicians and a workforce below adequate staffing levels

A census of the Emergency Medicine workforce in Scotland by the Royal College of Emergency has found shortages of key senior decision-makers, and a workforce that is below adequate staffing levels to deliver the best and most effective care to patients.

When asked for immediate staffing needs, Emergency Departments across Scotland reported they needed an increase of:

  • 25% in consultants
  • 45% in Advanced Clinical Practitioners/Advanced Nursing Practitioners/Physician Associates
  • 16% in Emergency Nurse Practitioners
  • 22% in Higher Specialist Trainees/Non-consultant Senior Decision-Makers
  • 21% in Junior Doctors

RCEM analysis shows that to resolve the shortages of senior decision-makers and to achieve adequate staffing and aspirational staffing levels by 2026 the current workforce in Scotland needs a total of 405 more health care staff broken down as:

  • 113 more consultants
  • 74 more Higher Specialist Trainees/Non-consultant Senior Decision-Makers
  • 38 more Advanced Clinical Practitioners/Advanced Nursing Practitioners/Physician Associates
  • 180 more Junior Doctors

RCEM’s Scotland workforce census consisted of a 64-question survey and was sent to Emergency Department Clinical Leads across Scotland.

Responses were received from 24 Emergency Departments, including all 20 consultant-led Emergency Departments, one Minor Injury Unit, and three Remote and Rural Hospitals.

Commenting on RCEM’s Scotland workforce census, Dr John Thomson, Vice President (Scotland) of the Royal College of Emergency Medicine, said: “The census clearly shows that the Emergency Medicine workforce in Scotland is not adequately staffed to deliver the highest quality patient care.

“This has led to an increase in intense pressures on the existing workforce and is very likely to be a contributing factor to the continued deterioration in performance.

“We have always been proud of Scotland’s performance in Emergency Medicine, ensuring quick and effective care that outperformed the rest of the United Kingdom. But, even before the pandemic, the increase in demand put severe pressure on staff, and departments began to struggle to meet the four-hour access standard, but more seriously began to struggle to deliver appropriate treatment to patients, resulting in more delays and longer stays.

“The pandemic certainly exacerbated these issues and now there are some major challenges that face Emergency Medicine in Scotland. Emergency Medicine can be relentless; a service delivered 24 hours a day, seven days a week, will always take its toll, and the pandemic has highlighted the severe burnout that Emergency Medicine staff, especially face.

“Departments must be staffed with a workforce trained and qualified in Emergency Medicine. Shortages in senior decision-making staff groups can lead to Emergency Departments over-depending on junior staff. The census shows that we need considerable expansion of funded consultant and senior decision-maker posts in order to prioritise patient safety and quality of care.

“We managed to survive the first two waves of pandemic with an insufficient workforce, but now these existing staff are facing burnout and exhaustion – with some clinicians reporting they are planning on retiring early. This census clearly shows that we must act and address these problems without delay.

“The Scottish Government must work with the specialty to devise an adequate workforce plan for the emergency care system, taking into account population needs and rising demand on the service. Plans must ensure sustainable and fulfilling careers for all staff, allowing for the delivery of quick, safe, and effective care for patients.

“Without a sufficient workforce plan that addresses the findings of the census, it is likely that there will be continued deterioration in Emergency Department performance and rates of burnout will continue to increase amongst Emergency Medicine staff.”

Health Secretary Sajid Javid: “We cannot eliminate COVID-19”

Learning to live with Coronavirus

Moments after the Prime Minister called to ask me to become Health and Social Care Secretary last Saturday night, I spoke to my teenage daughter in the kitchen (writes UK Health Secretary SAJID JAVID).

‘You won’t have much to sort out then, dad,’ she said sarcastically.

When I came back to Westminster on Sunday morning, I found the biggest in-tray I’ve had at any department – and I’ve run 5.

I’ve spent the last year working with Harvard University on how governments can learn from this pandemic and be better prepared for future challenges, now I’m the one faced with so many of those tough choices.

I feel both the heavy responsibility and urgency that comes with this job.

My first video call on vaccine progress had to be at the same time as the England-Germany match. It was all going well until JVT (Jonathan Van-Tam, the Deputy Chief Medical Officer for England) suddenly took off his headphones because he didn’t want to hear the score before he watched a recording of the match.

It was an honour to start the meeting by thanking the team who have delivered the rollout, including everyone in the NHS, the Vaccines Taskforce and the officials in my department.

Amid the endless policy memos and reams of data, I see 2 immediate challenges. The first is how we restore our freedoms and learn to live with (coronavirus) COVID-19. The second is to tackle the NHS backlog – something that we know is going to get far worse before it gets better.

We are on track for 19 July and we have to be honest with people about the fact that we cannot eliminate COVID-19.

We also need to be clear that cases are going to rise significantly. I know many people will be cautious about the easing of restrictions – that’s completely understandable. But no date we choose will ever come without risk, so we have to take a broad and balanced view. We are going to have to learn to accept the existence of COVID-19 and find ways to cope with it – just as we already do with flu.

The economic arguments for opening up are well known, but for me, the health arguments are equally compelling. The pandemic has hit some groups disproportionately hard.

Rules that we have had to put in place have caused a shocking rise in domestic violence and a terrible impact on so many people’s mental health. All the progress we have made is thanks to the sacrifices of the British people – and our phenomenal vaccine programme.

The jabs are working. The latest data from the Office for National Statistics shows that 8 in 10 UK adults have the COVID-19 antibodies that help the body fight the disease. The implications of this are huge.

Tragically, the last time we had 28,000 new cases of COVID-19 in a day, we saw about 500 people die each day. On Friday, we had almost 28,000 cases a day, but 24 times fewer people lost their lives.

There will always be the possibility that we have to deal with dangerous new variants that evade the vaccine but I encourage everyone to get their jabs now if they haven’t already done so. It is the single biggest contribution you can make to this national effort.

We have many other crucial health challenges that we need to confront. We protected the NHS to make sure it was there for everyone who needed care. The steps we took saved countless lives but also led to the build-up of a vast ‘elective’ backlog – checks, appointments and treatments for all the less urgent, but often just as important, health issues.

Because of the pandemic, we estimate that about 7 million fewer people than normal came forward for healthcare. Even if only some of that demand returns, we will see enormous pressure on the NHS.

To help meet this demand, build a better NHS and bust the backlog, we need to build on the changes we’ve all embraced through the pandemic, such as using NHS 111 to direct patients to the most appropriate setting to receive care, expanding the use of our pharmacies and encouraging more people to use the NHS app.

We have to keep doing all of that, and more.

Of course, if you are feeling unwell, you need to come forward. The NHS is always there for you – and now in many different ways.

We’re putting record levels of funding into the NHS. In March, we committed a further £7 billion of funding – including £1 billion to begin tackling the elective backlog and about £500 million for mental health services and investment in staff.

And we’re bringing so many more talented colleagues into the workforce. We have record numbers employed in the NHS, with more than 58,300 more staff in hospital and community health services since March last year, including over 5,600 more doctors and 10,800 nurses.

We’re also embracing technology to help staff spend less time on paperwork and more on patients.

It’s time to build on the spirit of innovation we’ve all embraced and use it for the other challenges we face: from finally fixing social care and putting it on a sustainable footing, to tackling the health inequalities that the pandemic has brought to the fore.

I’m determined we get that right.

There’s a lot of work ahead, but if we hold on to the spirit that has seen us through these difficult days, we will have a country that is not just freer, but healthier, too.

Prime Minister Boris Johnson is likely to confirm later today that all COVID restrictions will be lifted in England from 19th July, so-called ‘Freedom Day’, despite a rising number of COVID cases.

Scotland is more cautious, with a tentative date of 9th August, and Wales and Northern Ireland have yet to make any decision on further relaxation on restrictions.

Test and Protect to prioritise high risk cases as Covid numbers climb

Scotland’s Test and Protect contact tracing staff are to prioritise phone calls to high risk cases to ensure the system delivers maximum benefit as Coronavirus (COVID-19) case numbers increase.

SMS text messages will now be used more extensively for low risk index cases, with direct telephone calls continuing to be used for the most high risk cases.

All individuals are being encouraged to complete the digital contact tracing form, allowing contact tracers to consider where a case is high risk and should receive a phone call. This approach will allow capacity to be focused on the cases most likely to lead to further transmission of the virus.

Additional measures to maximise overall capacity across health boards are being implemented, including supporting ongoing recruitment processes in local contact tracing teams to ensure they can continue to meet agreed staffing deployment requirements, alongside additional surge workforce capacity being brought online in the National Contact Tracing Centre over the coming days.

Health Secretary Humza Yousaf said:  “At a time when we are facing a record high number of positive cases, our Test and Protect system has continued to operate well and, meeting our proxy measure,  the World Health Organisation criteria of closing 80% of close contacts within 72 hours.

“But the third wave of cases means that the Test and Protect system is now contacting record numbers of people each day.

“The shift in approach we are taking will mean more text messages going out and people getting online to report contacts and find information.

“This is a sensible and practical approach which will allow us to focus our contacting tracing efforts on the most high risk cases and prevent further spread of the virus.

“Contact tracers will continue to phone many of those who have tested positive but there will be a focus on more complex, high risk cases. We continue to look holistically at the system to ensure its resilience, including supporting ongoing local recruitment and flexing additional workforce capacity within the National Contact Tracing Centre.

“It’s really important that people who are contacted by Test and Protect continue to self-isolate for 10 days.

“Our Test and Protect staff are doing fantastic work under significant pressure and we should all be thankful for their efforts throughout this pandemic.

“I would encourage anyone who has a smartphone to download the Protect Scotland App – if you test positive, you will receive a code that can be entered into the app, providing isolation notifications to people you have been in contact with.”

Daily case numbers reached a record 4,234 in Scotland this week, although the success of the vaccination roll-out has limited the number of people getting seriously ill and being admitted to hospital.