Health and care professionals in Derbyshire are well-versed in working together to maintain services under pressure. Each part of the NHS is finely balanced in relying upon the role and expertise of others to make sure patients can continue to enter and progress through the service when they are ill. And when it comes to ambulances, this balance and coordination across all partners is often the difference in keeping the vehicles on the road.
The covid-19 pandemic has tested health and care services like nothing else before it and staff in Derbyshire continue to respond to that challenge every day. As the Covid-19 pressure has subsided through the summer, new pressures have emerged, partly due to the need to recover surgery waiting lists and due to an as-yet unexplained boom in the number of patients needing to access care. Resilience is being tested again, but each part of the health and care system remains committed to the ethos of joined up care. The experiences of services working so closely to deal with difficult times such as winter, and other times of pressure, has stood Derbyshire in good stead.
Gavin Boyle, Chief Executive at University Hospitals of Derby and Burton, said: “This continues to be a particularly busy time for the NHS. Normally summer is the quieter season but we’ve been exceptionally busy, particularly with high numbers of emergency and cancer patients. Despite the challenges, our staff continue to go above and beyond to provide exceptional care to every patient who needs us.
“We’re working hard to restore services with a view to ultimately returning capacity to pre-pandemic levels, including meeting the national targets such as emergency department waiting times, surgery waiting lists and the maximum time an ambulance should wait at an emergency department, but we can’t achieve this alone.
“At UHDB we are only one part of the puzzle. It’s critical that we work with our partners across health and social care to address challenges at every part of a patient’s journey. For example, having the right social care packages in place to support a patient’s discharge is crucial to helping them leave hospital for their onward care journey. This creates space for the next emergency admission to be transferred from the emergency department to a general ward and then in turn, an ambulance patient can handed over to the ED team releasing the paramedic crew to respond to the next patient waiting in the community.
"It's a very simple way of describing what we know as 'flow' within a hospital, but each element is a moving part that must align to get patients home safely and create space for the next one who needs us.”
The ambulance service has seen unexplained increases in calls over recent months, with most days being busier than the traditionally busiest days such as New Year's Eve. There was a 40% increase in calls – around 1000 actual calls per day - in July 2021 compared to July 2019 and at its peak, East Midlands Ambulance Service received 5000 calls in one day, when 2500 would usually be regarded as a 'challenging' day.
Modern ambulance crews and so skilled and well-equipped that they can treat patients more and more patients at home or signpost to alternative services where possible, so through their expertise, crews ensure that not all 999 calls need to result a trip to hospital. In fact, only 58% of patients were conveyed to hospital compared to 65.5% over the same period last year, which equates to more than 5100 patients who were treated at home rather than in hospital across the East Midlands. Even so, visits to patients by ambulance crews are up 8% on July 2019, around 140 more face-to-face ambulance responses per day.
Tim Slater, Divisional Director for East Midlands Ambulance Service in Derbyshire said:
"When patients do need hospital care, emergency departments are often busy on arrival through dealing with patients who have walked into the unit. The challenge this creates for ambulance crews is that when they arrive at a full emergency department, they may need to stay longer with a patient for an extended period before a hospital clinician is available to take over the care."
"The national target is for hospital emergency departments to accept a clinical handover from ambulance crews when they arrive at hospital with a patient within 15 minutes. Derbyshire has historically performed well against these handover targets, and teams continue to develop and access alternative services within the community. During 2020/2021, East Midlands Ambulance service lost 59,759 hours to pre-hospital handover delays, compared to 92,088 hours lost during 2019/2020, equating to the loss of nearly 5000 12-hour vehicle shifts. The reduction in hours lost is positive news and can be attributed in part to the number of times crews are able to treat patients at home, along with continued work with emergency department teams to streamline the handover process."
"The outcome for patients of handover delays is obvious, with delays in getting crews back out on the road, patients waiting longer in the community, often without a medical professional present, for a 999-ambulance response. Patients also experience some delay in getting the hospital treatment they need. The situation also impacts on staff wellbeing, morale and sickness levels. Everyone can help this current challenge by relieving congestion at our emergency departments wherever that is possible, by using NHS 111 online – www.111.nhs.uk - or by calling 111 to receive advice and to book ED appointments, and also appointments for urgent treatment centres and their GP if needed."
Despite the pressures, patients can still expect good quality care when they arrive at hospital, and services continue to aim to meet the national four hour waiting time target for emergency departments, despite this having been a significant challenge to meet during the last 18 months.
Rachel Traveller, Assistant Service Manager for the Acute Care Unit at Chesterfield Royal Hospital said:
“We’re continuing to see an increase in the number of people coming through the doors of our Emergency Department, but we have a good record for seeing, treating, admitting or discharging within the national four hour standard. There has been a significant demand on services across the entire NHS system, coupled with a staff shortage caused by illness and Covid-related isolation that has increased this pressure and impacted our ability to consistently meet the 15 minute target to handover ambulance patients. But at no point will our patients be left to wait outside or in ambulances; they wait in our ED upon arrival whilst the handover takes place."
“There are ways the public can help with this by reducing the pressure on the system and making sure the right services are accessed at the right time for the right health concerns. By doing this, all of our emergency services teams will have greater capacity to enable our care teams to treat patients quicker and more effectively.”
Once treatment starts in the hospital, patients are often admitted to a hospital bed for their onward treatment. Ward staff are working tirelessly to manage the care for what has been an increase in sicker patients who often require longer stays in hospital. When wards become full, the increase in admissions can affect patient flow within the hospital and lead to waits for the transfer of patients from emergency units. When patients are recovering and nearing the point that they can be discharged either back home or to a different service, having a discharge plan in place in good time is crucial to avoiding a delayed discharge. This involves staff from a range of teams, including hospital and community physiotherapists, adult care staff, nurses and sometimes mental health support teams. Any delays to discharges mean that the pressure on beds intensifies and that hospital staff have challenges ensuring there is enough space for new patients needing care.
Councillor Roy Webb, Cabinet Member for Adults, Health and Housing,Derby City Council, said:
"The role of adult social care service's in making sure hospitals are able to treat all patients is not widely known among the general public, but is a vital cog in the wheel. Whether we are taking care of a patient in one of our 'step-down' facilities, which are used when someone may no longer need nursing care but still needs support before going back home, or putting in a care package at home requires a lot of coordination, including with the patient and their families. We have been asking recently for families to be ready to help in getting the home ready when that discharge decision is made and not only does this free up the bed on the ward for the next patient, but any delay at this stage in the care journey sees a ripple effect back through the rest of the hospital, which ultimately can result in possible ambulance delays at the hospital front door."
"We are very good at working across the different teams and have excellent relationships. This doesn’t necessarily always mean it is easy to solve the challenges, but it goes a long way to building the trust and knowledge that everyone is doing everything they can and that is reassuring both for us as individual system partners, but more importantly for the patients."