COMMENTARY

'Magic Money Tree' & Resetting EDs 

Dr Dan O'Carroll

Disclosures

August 14, 2020

The UK Government is persisting with its overarching message that it has responded well to the global COVID-19 pandemic, despite growing evidence to the contrary. It can lay claim to the UK having had the highest excess deaths in Europe by May, and despite the measures taken to protect the economy, it has overseen the deepest recession of any major economy, with UK economic output shrinking by 20.4% in the second quarter. The Prime Minister remains insistent that the UK's track and trace system is 'world beating', despite many experts being gravely concerned regarding the number of close contacts the system is failing to reach, and that many local authorities have had greater success in managing recent local outbreaks then the expensively outsourced centralised system, and with a fraction of the resources.

The Government has been more than willing to shake the 'magic-money tree', whose existence was previously denied, in a panicked manner, to make up for years of chronic underfunding for many (now) key areas. This has led to huge sums of money being spent in an effort to support the economy and to support the NHS and social care sector in their response to the pandemic. Many companies with no obvious relevant background have 'won' huge contracts without going through a competitive tender process, due to the urgent demands of the pandemic, and this has resulted in some 'sub-optimal' results, including the purchase of 50 million FFP2 masks at a cost of somewhere between £156 and £177 million. It is surely just unfortunate that these masks are unusable for the NHS as they do not provide an adequate fit.

Performance

During the peak months of the pandemic, attendances to emergency departments (EDs) dropped drastically, for a variety of reasons, and the Government hope is that this [increased] funding will be used to restore public confidence that it is safe to visit the ED, as strict social distancing and hygiene measures are in place.

Performance against the Government's '4-hour target' improved hugely and this was not just the result of fewer attendances but also as a result of improved inpatient capacity, as hospitals had reduced elective activity and managed to clear some of the 'medically fit for discharge' patients. This demonstrated what many of us had said, ie, that the EDs could meet the 4-hour target if the exit block was removed. It also was a stark reminder that this was not an insolvable problem. There is some bitterness that the ED staff and patients had been subjected to terrible conditions from overcrowding for the preceding several years due to political decisions and financial constraints.

As the latest hot spell of the summer hits the UK, many EDs are back to pre-COVID levels of activity. Despite nominal maximum capacities in EDs being stated, these can be rapidly exceeded by a sudden influx of emergency patients, with the 'alert phone' ringing almost constantly, pre-warning of yet another seriously ill or injured patient arriving imminently. Some trusts have taken to holding patients in the ambulance rather than allowing them into an already overcapacity ED.

Royal College of Emergency Medicine Vice President Adrian Boyle and President Katherine Henderson call for a 'resetting of ED care' in the editorial of the July Emergency Medical Journal. They set forward six recommendations (below), as well as making the bold statement: 'EDs should return to their original core purpose: the rapid assessment and emergency stabilisation of seriously ill and injured patients', rather than being the default when there are gaps in other services.

  1. Improved infection control

  2. Reduced crowding and improving safety

  3. Patients under the care of specialist teams

  4. Physical ED redesign

  5. Using COVID-19 testing for best care

  6. Metrics to support reduced crowding

Other than the COVID-19 testing, these recommendations could have been considered an urgent priority even prior to the pandemic, as we have been aware for many years that overcrowding in the ED causes harm to patients. Perhaps now there is the political will to act on it this time. There is no question that if we were to carry on as normal, with dangerous levels of crowding in our EDs going into this next winter period, many patients would come to harm, and we would not be able adequately to protect staff as well.

It should be welcomed that the Government this week announced a £300 million package to be shared between 117 acute trusts to 'upgrade A&E facilities' in an effort to prepare for winter and the potential risk from further outbreaks of coronavirus. Compared with many recent decisions, this seems to have been made with some forethought rather than being reactionary.

How Is This Money Going to Be Spent?

Trusts may try to relieve pressure on the ED by increasing their overall bed capacity to release physical space back to the ED, or they may look at increasing ED cubicle and waiting room capacity, whilst improving other emergency assessment areas, but what is clear to me is that there is no time to waste in setting these plans in motion.

An area of concern that is not likely to be addressed by this funding though is access to primary care. Our GP colleagues need to be enabled to get their services back fully running and functional and be given the additional resources if required to manage the lower acuity problems that would otherwise attend the ED.

Many of the hurried decisions that have been enacted by the Government have appeared to have been made too late, which has left the services playing catch up. This new funding needs to have been used and up and running before the winter truly hits. The thought of trying to deal with a busy seasonal flu as well as an on-going COVID-19 situation is disturbing, and we need to use the remaining time available to ensure that the departments are set up as well as they can be. Although they were largely unused, the phenomenal achievement in building the Nightingale hospitals from scratch needs to be replicated on smaller scales across the country in most of the departments. I hope the political will and urgency remains to ensure that this is completed in time.

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