A potential crisis in hospital care is widely reported in the media today, with BBC News reporting that standards of hospital care are slipping throughout England. The Daily Mail states that elderly patients are being shunted between beds “like parcels”.
The headlines are based on a new report by the Royal College of Physicians (RCP) of London, which warns that acute hospital care is under pressure, leading to “unnecessary pain, indignity and distress”. Many stories lead with the frightening claim that NHS hospitals could be on the brink of “collapse” – a term that the RCP’s report does not use, but which is present in its accompanying press release.
The title of the report is Hospitals on the edge? The time for action.
The report does not discuss specific clinical outcomes, other than increased mortality rates for people admitted during the weekend. The study raises a number of legitimate concerns, such as:
- there are a third fewer general acute beds than there were 25 years ago despite a 37% increase in emergency admissions in the past decade
- problems with continuity of care, with elderly patients sometimes being moved by “bed managers” four or five times in one hospital stay
- the quality of services was found to drop during the night and at weekends
The report concludes by calling for radical action to review and reorganise hospital care so that “patients receive the care they deserve”.
Who produced the report and how reliable is the evidence?
The report has been produced by the Royal College of Physicians (RCP), an independent membership body that sets and monitors standards of medical training and care in England. The RCP performs a wide range of activities, aimed at safeguarding and improving standards of clinical care and public health. As the RCP’s members are mainly doctors practising within the NHS, they have a clear interest in how the NHS is run. That is not to say that the concerns raised are not legitimate.
The report bases its description of the problems in acute hospital care on a variety of reputable sources including reports from the King’s Fund, the Parliamentary and Health Service Ombudsman, the National Institute for Health Research and the General Medical Council. Its report also draws on previous RCP publications, including surveys of and conversations with hospital doctors. As such, it draws on reliable sources of information to describe the increasing pressure on acute hospital services and to make the case for change.
What does the report find?
The report sets out in detail five key pressures facing hospital acute services:
The report finds that there are one-third fewer acute beds than there were 25 years ago, but the past decade alone has seen a 37% increase in emergency admissions and a 65% increase in hospital stays for those over 75. Despite the high cost of hospitalisation for emergencies, the NHS has been slow to develop effective alternatives to emergency admissions in the community.
Changing patients, changing needs
Nearly two-thirds of people admitted to hospital are over 65 and an increasing number are frail or have a diagnosis of dementia, while people over 85 now account for 25% of “bed days”, the RCP report finds. All too often hospital buildings, services and staff are not equipped to care for elderly people who have multiple, complex needs including dementia, it says. The report cites research showing that medical and nursing staff feel elderly patients “shouldn’t be there”, an attitude that reduces the quality of care and results in resentment.
The greatest concern is lack of continuity of care, with a quarter of the RCP’s members surveyed rating their hospital’s ability to deliver continuity of care as ‘poor’ or ‘very poor’. They say it is common for patients to be moved four or five times during a hospital stay, and this particularly affects elderly patients being moved to outlying wards during the night. Decisions are often made by “bed managers” and patients may be transferred without any formal handover, while patients who do not fall neatly into any specialty may become neglected.
The report describes the experience of an elderly confused patient who was: “wheeled by a porter from her treatment to the entrance door and left there … she wore an incontinence pad that was saturated and the chair was also saturated with urine … No one spoke to her or tried to help her. She was just ignored”.
Out of hours care breakdown
Emergency admissions at weekends are around a quarter lower than during the rest of the week and there is a fall in the number of procedures performed on Saturdays and Sundays, the report says. It says this suggests that patients who need care are being “pushed” into the following week. The report says research suggests mortality is often 10% higher among patients admitted at weekends, when less experienced doctors are on site.
Looming crisis in the medical workforce
The report says the reduced working hours of junior doctors imposed by the government as well as EU directives, has seen many specialties move to shift pattern working, which potentially has a negative effect on patient care. It also says that three-quarters of hospital consultants report being under more pressure now than they were three years ago, and more than a quarter of medical registrars report an unmanageable workload. Recruitment into emergency medicine is becoming difficult, it says, with an increasing reliance on locums and unfilled consultant posts. Application rates into training schemes involving general medicine are also declining, the RCP report says.
Why does the RCP think acute hospital services are under strain?
The report says one underlying cause of the pressure on acute hospital services is the changing demographics in Britain since the NHS began in 1948. There are 12 million more people now than then, and life expectancy at birth is around 12 years longer, while people aged 60 or over make up a quarter of Britain’s population.
In many ways, the NHS is a victim of its own success. Universal healthcare has led to an improvement in life expectancy, which results in an increasingly elderly population with complex health needs.
What are the RCP’s recommendations?
The RCP has identified 10 priority areas for action to transform care. Governments, employers and royal medical colleges must be prepared, the report argues, to make difficult decisions and implement radical change where needed. In particular, the RCP report is calling for:
- health professionals to promote patient-centred care and treat patients with dignity at all times
- a redesign of services, led by clinicians, to meet patients’ needs
- the reorganisation of hospital care, including changes to working patterns, so that patients can access expert services seven days a week
- a review of medical education and training to ensure the correct balance of general and specialist skills, including skills needed in caring for older patients
- plans to ensure the right mix of medical skills
a renegotiation of the New Deal (the measures agreed between the government and the profession which place limits on the hours worked by junior doctors)
- improved access to primary care including at night and at the weekend
- a radical change in use of information about patients – so that it moves with them across the system, for example, improvements in electronic patient records
- delivery of quality improvements throughout the system, using tools such as clinical audits
- national leadership – the report says national standards and systems must be implemented where this is in the interest of patient care
The report highlights important issues, such as pressure on acute bed spaces in the NHS, the need to train more ‘generalist’ doctors and the importance of the adaptation of the NHS to treating an ageing population. It serves to spark a debate about how NHS services can be improved, and that is always welcome. However, many of the issues highlighted by the report, such as increased mortality rates during the weekend, have been a known concern for some time. The recommendations of the report are likely to be of use to policymakers, rather than individual doctors or health managers. The use of the term ‘collapse’ in the accompanying press release is emotive and unhelpful, although may go some way to explaining why so many papers wrote up the story.