Winter resilience: Overcoming seasonal pressures to make winter business as usual 

Tackling A&E waiting times

A&E departments are often the busiest places in a hospital, handling a diverse range of patient cases. The challenge lies in delivering timely care while ensuring optimal resource allocation. A&E departments saw over 6.5 million attendances in June – August 2023, surpassing the previous record in 2019 by more than 20,000.  

Operational targets set by the government aim to improve Urgent and Emergency care, including admitting, transferring, or discharging 76% of patients within four hours by March 2024. However, the Royal College of Emergency Medicine considers the 76% target unambitious. It warns that patients will continue to face long waits if this trend continues, potentially impacting ambulance response times further. In 2004, 98% of patients left A&E within four hours. 

Performance below 75% is considered a significant patient safety risk, resulting in long waits in crowded A&E waiting rooms and worsening conditions before treatment. The Royal College of Emergency Medicine estimated long A&E wait times resulted in 23,000 excess deaths in 2022. 

The median waiting time for A&E patients increased from 2 hours 9 minutes in May 2011 to 2 hours 54 minutes in December 2019 before nearly doubling to 5 hours 59 minutes in March 2023. Current data analysis by CHS Healthcare, part of Acacium Group, indicates that, based on current trends, NHS targets will not be met. By December 2023, only 66% of A&E attendances will meet the four-hour target, falling short of the 76% NHS goal.  

Source: https://www.nuffieldtrust.org.uk/resource/a-e-waiting-times

Diagnosing the problem with A&E Consultancy services 

Acacium Group’s A&E consultancy utilises the newly available Emergency Care Data Set (ECDS), a standardised dataset produced by every trust in the country. Comprehensive data analysis involves cleaning, processing, and modelling the data to create interactive dashboards that provide a holistic view of A&E department performance.  
 
Reviewed and presented by experienced clinical and management consultants, Acacium Group’s experts provide actionable insights on how leaders can optimise resources and operations for a better patient experience. The former National Clinical Director for Emergency Care at NHS England, Professor Matthew Cooke, forms part of this team and has worked with trusts to identify quick wins and long-term solutions to their challenges, including; 

• Patient arrivals and seasonality: Data analysis reveals when patients typically arrive by the hour, allowing hospitals to adjust staffing and resources accordingly. For instance, in this trust’s example, Mondays are often the busiest days, reflecting weekend cases that wait until the start of the workweek. 
• Bottleneck identification: Data highlights bottlenecks, such as delays in discharging mental health patients at night. This knowledge enables hospitals to allocate resources and support more efficiently. 
• Optimisation: Data insights reveal variations in productivity and efficiency. Hospitals can analyse days when they meet the four-hour A&E target and identify days when they don’t, uncovering productivity issues and staffing needs. 
• Patient complexity: Data analysis helps hospitals understand the mix of patients, their conditions, and the complexity of cases. This information is crucial for resource allocation and optimising care. 

Urgent Treatment Centres 

The standardisation of various services into Urgent Treatment Centres (UTCs) has been a central part of urgent and emergency care reform in recent years. UTCs have been established alongside many Emergency Departments in England to divert work away from the A&E to enable the emergency care staff to focus on managing the more seriously ill and injured.  

While UTCs are classified as type three A&E units and contribute to four-hour wait statistics, their primary role is community-focused care rather than an extension of traditional A&E departments. UTCs are open at least 12 hours a day, every day, and offer appointments that can be booked through 111 or a GP referral. Data from 2021-2022 indicates that UTCs are becoming increasingly integrated into the urgent and emergency care pathway, but there is room for more effective utilisation.  

Professor Matthew Cooke believes UTCs play a crucial role in alleviating the burden on Emergency Departments, but to be effective, they must have clear staffing, administration, and patient prioritisation guidelines. A best practice approach to the launch and management of UTCs can ensure trusts and patients benefit, ensuring patients receive prompt and appropriate care. 

Professor Matthew Cooke believes UTCs play a crucial role in alleviating the burden on Emergency Departments, but to be effective, they must have clear staffing, administration, and patient prioritisation guidelines. A best practice approach to the launch and management of UTCs can ensure that trusts and patients benefit, ensuring prompt and appropriate care. 

As a CQC registered provider with a proven track record in delivering NHS-managed services contracts, Acacium Group’s bespoke insourcing solutions enhance Urgent and Emergency Care performance.  The Group can call on a vast network of GPs, ENPs, and A&E doctors, accommodating many patients and conditions across minor illness and injury pathways. 

These GP-led services maximise capacity during periods of high demand, including evenings and weekends. On entry, the triage nurses assign patients to either Minor Illness or Minor Injury pathways based on their symptoms. This frees up time for nurses and clinicians to concentrate on treating more complex patients while maintaining clinical oversight of the insourcing service. 

Once admitted, Acacium Group’s experienced medical professionals, including GPs, ENPs, and Junior Doctors, provide immediate care. They arrange community follow-up, hospital referrals, or primary care support based on the patient’s needs. This maximises the number of patients that can be seen per hour, depending on facilities, like the availability of plaster and dressing services.  

The key service outcomes include: 

• Improved performance: Reduced patient waiting times and decreased the total time patients spent in the department, enhancing overall efficiency. 
• Effective use of resources: Auditing the number of tests ordered, admission rates, and re-attendance rates to optimise resource utilisation. 
• Patient flow management: Acacium Group dedicates teams to safeguard patient flow into the UTC, even when there’s an increase in demand for emergency physicians. 
• Enhanced clinical focus: By providing insourcing services, the service frees up time for nurses and clinicians to concentrate on treating more complex patients while maintaining clinical oversight. 
• Community follow-up: Acacium Group establishes connections with primary care services to arrange community follow-up when necessary, reducing emergency department re-attendance rates. 
• Patient satisfaction. People with minor injuries are seen more quickly by clinicians who do not get pulled away to more urgent cases. 

Offering flexible commercial models, UTC services can be tailored to meet specific local needs, catering to all age groups and addressing mental and physical health problems.  

Intelligent patient flow and expedited discharge 

There’s no getting away from the fact that hospital discharge impacts admissions. Efficient discharge is crucial in making space and getting incoming patients the care they need. In December 2022, a daily average of 13,440 patients continued to occupy hospital beds despite no longer meeting the eligibility requirements, marking a 30% increase compared to the daily average for December 2021.  

Speaking to the Healthcare Safety Investigation Branch (HSIB) in 2023, NHS England staff disclosed the impact of being unable to discharge patients into social or community care. They highlighted how late discharge resulted “in further medical intervention and an extended stay in hospital”. In addition to impacting patient flow right across the system, the Health Foundation has highlighted how delayed discharge affects patients’ health, mobility, and independence, posing a further threat to resources in the long term. 

Research from CHS Healthcare, part of Acacium Group, revealed that 31 distinct tasks and communication points are involved in discharging medically optimised patients from hospital. These tasks encompass paperwork completion, transportation arrangements, and funding approvals. Nearly half of hospital employees and over half of social care workers surveyed acknowledged that administrative procedures are responsible for discharge delays.

• In 31% of cases, discussions about hospital discharge only occur when treatment is nearing completion or when the patient is medically ready for discharge.  
• 18% of staff members agreed that patients are admitted without a clear discharge plan despite discharge planning guidelines.  
• 50% of hospital staff admit that resistance from patients’ families and caregivers to the final discharge decision causes delays, which can be mitigated through more timely and effective communication. 

In the case of frail and elderly patients, discharge is often postponed due to the challenges faced by the patient’s family in locating and selecting an appropriate care home. Several obstacles come into play, such as the difficulty in finding a care facility with available space or one that can cater to the patient’s complex or personal needs. Additionally, family members might find themselves overwhelmed or in disagreement, which collectively impedes the decision-making process and leads to delayed hospital discharges. 

Hospital discharge services 

CHS Healthcare offers hospital discharge management services that focus on patients at risk of significant delays in getting out of hospital. These services can be customised to align with organisational objectives through flexible and outcome-focused commercial agreements. CHS operate seven-day services to ensure that patients receive the necessary care and support, further maximising the opportunity to discharge patients and improve patient flow safely. 

Working as an extension of hospital discharge teams, the service addresses barriers that result in delayed transfer of care. This includes bringing forward the discharge planning in the patient journey, often starting at admission, and streamlining the discharge process. This can involve coordinating with care homes, arranging transportation, sourcing appropriate care in the home, and maintaining effective communication with family members.  

The service places a strong emphasis on the quality of reporting. Delays are promptly addressed, and opportunities for improvement are continuously sought. This approach leads to substantial enhancements in the speed of discharges and provides valuable business intelligence to commissioners. Effective case management and targeted care ensure that less than 2% of patients are re-admitted to the hospital, supporting further cost and efficiency savings. 

Supported discharge has been used to great effect throughout Durham’s integrated care system, with CHS delivering on priorities around discharge access management and discharge delays.  Over the last five years, the service has grown and evolved to fit the Trust’s requirements. Working across all hospitals within County Durham, the service also completes trusted assessments for care home providers where requested. 

Between October – December 2022, working in partnership with Durham’s ICS, CHS has delivered; 

By leveraging timely assessments and end-to-end case management, more patients are enabled to return to the safety and comfort of their own homes. Accelerated patient discharge improves patient flow to benefit providers and enhances the patient experience. 

Effective discharge services reduce the stress associated with the uncertainties of leaving the hospital. Families value the personalised support offered during a challenging time, with more than 100% of service users consistently rating the support as ‘excellent’ or ‘good.’ 

Keeping elective services running 

In the past, the growing demand for Urgent and Emergency Care services has resulted in redirecting trust resources away from elective care services. This year, elective care challenges as we enter the winter season with the most extensive waiting list on record. This situation is exacerbated by ongoing industrial action from consultants and junior doctors and a persistently high staff turnover, further diminishing system capacity. 

The British Medical Association’s analysis of the NHS’ backlog data reveals how significantly COVID-19 has impacted elective care service delivery. Before the pandemic in February 2020, there were already 4.43 million people on care waiting lists. Figures from September 2023 reveal there are now 7.75 million patients waiting for treatment in England alone. 

Insourcing and outsourcing services 

Xyla, part of Acacium Group, are a clinically-led, CQC-registered, managed service provider that provides clinical teams, governance processes and oversight to acute hospital trusts, community services and independent providers. Xyla services bring together patient flow, diagnostics, surgery and outpatient care, protecting quality and patient experience. 

As a CQC-registered, multi-disciplinary provider of elective care services, Xyla supports more than 50 NHS trusts to reduce waiting lists through efficient patient flow management. This is achieved through a combination of strategies, including referral triage, enhanced advice, and guidance in elective care and referral assessment.  

Services also provide additional capacity through risk stratification, digital-first clinical pathways, one-stop clinics, and the strategic utilisation of insourced and outsourced teams. Increasingly, digital solutions are playing a pivotal role in the process, facilitating remote triage, patient booking, and management and enabling patient-initiated follow-up. This integrated approach ensures a streamlined healthcare experience, leveraging technology and strategic clinical pathways to enhance both the accessibility and quality of patient care. 

Xyla has developed several strategic partnerships with national estate management and modular building providers, enabling us to offer alternative premises to deliver a fully managed service to manage clinical capacity to benefit patients, ICS and trusts. These alternative premises are easily accessible and can integrate digital and community delivery models. Fixed and mobile premises offer multiple flexible options to best meet providers’ backlog, patient needs and funding. 

Teledermatology is an example of these strategies elevating services for vastly improved patient outcomes. Xyla provided a digitally-enabled teledermatology service to the Frimley Integrated Care Board (ICB) following routine dermatology waiting lists exceeding 80 weeks. The service provided virtual triage, diagnosis, monitoring, and evaluation of various skin conditions, aligned with British Association of Dermatologists guidelines. 

Working with Frimley ICB, a customised approach was implemented to facilitate the referral process for patients by GPs. This accommodated referrals with or without dermatoscopic images. Acacium Group also provided a medical photography clinic, ensuring prompt access to photos within 48 hours for higher-risk patients and no more than ten days for routine cases. 

The introduction of teledermatology allowed the Trust to proactively treat patients within the community whenever feasible, resulting in a 40% reduction in two-week wait referrals sent to secondary care. Waiting lists reduced from 560 days to two, significantly improving patient flow, alleviating patient’s concerns and, in complex cases, saving lives. 

Maintaining staffing levels through winter  

Staffing challenges aren’t limited to winter. However, as the cold weather drives an increase in patients suffering from seasonal illnesses, healthcare workers are also more susceptible to falling ill. This creates a challenging scenario where the demand for healthcare services surges precisely when the workforce’s capacity may be compromised. 

The remaining workforce is under greater pressure, stretching the limits of the care they provide. Over a sustained period, this impacts employee’s health and wellbeing, further diminishing the workforce and leading to burnout and unprecedented levels of people leaving the NHS. Nearly 170,000 workers left their jobs in the NHS in England in 2022. 

The Healthcare Safety Investigation Branch (HSIB), responsible for overseeing safety within England’s healthcare system, reported that many NHS staff interviewed during a national investigation exhibited emotional distress when discussing their work environment. 

Maintaining staffing levels through winter is a complex challenge that requires a coordinated effort from healthcare leaders across the public and private sectors, staff, and policymakers. Speaking at the Public Accounts Committee about staffing challenges in mental health, Dame Meg Hillier MP, Chair of the Public Accounts Committee, said, “Invaluable care for some of our most vulnerable cannot and must not be provided at the expense of the welfare of the workforce carrying it out.” 

The sustainability of healthcare organisations hinges on the wellbeing of their workforce. Having the capacity and resources to meet demand is central to safeguarding the workforce’s health and avoiding burnout. However, addressing healthcare staffing challenges is not a one-size-fits-all solution.  

Providers must consider different approaches, from immediate solutions to proactive strategies, culminating in strategic partnerships that can drive more cost-effective use of resources. By choosing the right approach, healthcare organisations can better navigate the complexities of staffing during challenging seasons, ensuring high-quality care delivery while focusing on their long-term objectives. 

Winter ward management 

Recognising the limitations of ad-hoc supply, healthcare institutions are increasingly exploring proactive solutions to address their staffing challenges. Acacium Group’s managed staffing services are designed to guarantee that the right staff will be available when needed. This means that the NHS can rely on a pool of qualified healthcare professionals who can be called upon to fill critical staffing gaps, ensuring that patient care remains consistent and of the highest quality. 

Rather than simply plugging gaps in provision, this approach seeks to tailor solutions that address the root causes of staffing issues. It’s about engaging in a collaborative effort to design and implement strategies that solve immediate problems and ensure the healthcare trust’s long-term success. Winter ward management is one approach that has been successfully engaged by proactive trusts looking to face winter challenges head-on.  

Acacium Group’s managed staffing service provides a complete team of experienced nurses and healthcare assistants who are specifically dedicated to operating and managing winter wards. Collaborating with existing teams to ensure that the ward operates in accordance with agreed-upon service levels, service leads consider specific operational requirements in the design and implementation of the service.  

Winter wards are, by nature, designed as short-term healthcare solutions. This adaptability allows healthcare facilities to efficiently allocate their resources and respond to the fluctuating needs of their patient population, ensuring that they are well-prepared to meet the healthcare challenges posed by the winter season. 

With guaranteed service availability, streamlined staff rostering, and administrative support, these wards allow in-house teams to focus on core hospital activities. This provides much-needed clinical capacity and frees up resources to consider long-term staffing solutions.  

Winter wards operate with fixed costs, eliminating the uncertainties associated with variable expenses tied to agency staffing. This financial predictability is essential for healthcare facilities to plan and allocate their budgets effectively during winter. 

Adopting a proactive approach, such as winter wards, enables healthcare providers to allocate resources more efficiently, reducing the need for temporary staff and maintaining consistent quality of care. This approach is more sustainable in the long term and promotes staff stability, fostering a culture of continuity and excellence in patient care. 

Encompassing specialist staffing and services businesses, Acacium Group can tailor bespoke solutions to meet provider’s needs. CHS Healthcare and Pulse, both part of Acacium Group, collaborated to support Derby and Derbyshire Integrated Care Board to address a severe shortage of available bed space for medically optimised patients.  

Specially trained staff provided 24/7 care on the nurse-led surge unit, alleviating the hospital’s resource challenges. This resulted in a 15-hour discharge turn-around from referral, ensuring patients could return to the comfort of their homes more quickly. A 24-hour post-discharge follow-up call ensured a seamless transition and successfully prevented readmission.