Dedicated hospital units designed to treat emergency medical patients for up to 72 hours are now under such intense demand that specialists are often forced to provide care in emergency departments.
Writing in The BMJ (03 July), Dr Tim Cooksley, president of the Society for Acute Medicine (SAM), and colleagues warn acute medicine is “wilting” and that the spiral of decline in urgent and emergency care may not yet have reached its lowest point.
Acute medicine deals with the immediate and early treatment of adult patients with a variety of medical conditions who present to hospital as emergencies.
The specialty receives the majority of patients admitted from A&E onto acute medical units and helps maintain the flow of patients through emergency departments to avoid exit block, the term used when patients cannot be moved into a hospital bed.
“The ideal acute medical unit needs sufficient capacity to process acute admissions and keep patients who do not require transfer to a speciality unit to stay for up to 72 hours as this continuity reduces length of stay,” said Dr Cooksley.
“However, acute medical care is now routinely being delivered by teams in emergency departments rather than in optimal environments and this is both very difficult and worrying.
“Sadly, older patients often bear the brunt of the problem which causes significant risk and increased mortality.”
Dr Cooksley said the rate of the rise in 12-hour waits in emergency departments was “gravely concerning” and warned current trajectory suggests winter 2023 will be worse than the “dire experience” of 2022.
In January, 42,725 patients waited more than 12 hours in England’s EDs for an inpatient bed. This compares to 16,558 in January 2022 and 2,847 in January 2020.
In March, 39,700 patients waited more than 12 hours in ED compared to 22,500 and 1,184 in the same month of 2022 and 2020 respectively, while the latest data, for May, showed 31,500 patients were delayed over 12 hours compared to 19,700 in May 2022.
“NHS urgent and emergency care is under intolerable strain and this strain is increasingly causing harm to patients,” said Dr Cooksley.
“Timely and high-quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints.
“Whilst the Covid-19 pandemic has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decade long and, unless urgent action is taken, we may not yet have reached its nadir.”
He added: “Despite the publication of the NHS Long Term Workforce Plan last week, the reality is that there are currently 112,000 clinical vacancies and it is a 15-year strategy – it isn’t going to provide an immediate turnaround.”
Dr Cooksley and colleagues pointed to the latest Society for Acute Medicine Benchmarking Audit (SAMBA) from June 2022 to demonstrate the detrimental impact of the situation on supporting acute medicine to help deliver urgent and emergency care and whole system recovery.
“Our most recent SAMBA data reiterates the picture of a rapid decline in clinical performance, with acute medical patients not only enduring long waits in EDs, but also increased waits for key indicators of quality such as initial clinical review, time to consultant review and monitoring of their physiology,” he said.
“Acute medicine is at the heart of finding opportunities to mitigate the current crisis and future innovative, adaptive, high quality and sustainable urgent and emergency care, but the speciality, like all NHS and social care service, is wilting and unable to meet demands.”
He and his colleagues said the fundamental components of specialty – acute medical units, ambulatory emergency care (rebranded in England as Same Day Emergency Care (SDEC)) and evolving acute medicine-led hospital at home models – must be properly resourced and not overlooked.
“The principles of acute medicine are essential to achieve recovery and must be resourced to deliver their potential, but too often we see a futile search for the “magic bullet”, with assessment and care pathways that appear sensible but with limited or no evaluation performing poorly when deployed in real-world healthcare settings,” they explained.
“For example, the selection tools for SDEC, the performance of COVID virtual wards and NHS England’s “Reasons to Reside” criteria for discharge decision-making have all failed to meet expected performance levels when evaluated due to a lack of preparation prior to rollout.
“Acute medicine offers significant opportunities for service innovation, but this must be as part of a learning health system where services are properly staffed and funded, evaluated and refined in accordance with evidence.”
Dr Cooksley and colleagues said that while critics argue failings in the delivery of urgent and emergency care are not new, “this notion must be dispelled” as “the decline has been sustained”.
“While it is true that more people are accessing emergency care, this increase alone does not explain the disproportionate drop in performance. This situation must not become an unacceptable new normal or indeed continue the current spiral of decline.
“We urge system leaders to listen to our concerns, realise the potential of acute medicine to support urgent and emergency care and wider NHS recovery and ensure that focus, resource and energy is put into progressing the evidence-based solutions we know will help us to overcome the current challenges.”