We have to discharge two wards a day to keep up with new admissions; Alex Hickey talks to Dr Olwen Williams on the continuing challenges facing our NHS.
NHS services appear to be stretched to the limit this year. On an almost weekly basis the Daily Post has reported stories of the pressures A&E departments in particular have been under, and the impact that's had on you.
We've featured images of ambulances queuing up in hospital car parks as they wait to handover patients.
A Norovirus outbreak has also meant some general wards being closed to new admissions.
And we've reported on the closure of wards at community hospitals such as Bryn Beryl, Pwllheli to allow A+Es at Bodelwyddan, Bangor and Wrexham, to cope with a surge in patients over the winter.
In a special report Alex Hickey asks the Betsi Cadwaladr University Health Board chief of staff Dr Olwen Williams why demand for emergency services is so high, and what is being to done to address it.
Q Why have there been so many problems this year with waiting times at A&E and subsequent admissions into hospital? A What's been happening across North Wales is our numbers are going up 10% across the board. The average yearly attendance at all the region's hospitals is around 182,000.
The population of North Wales is about 600,000 so that gives you a context of the number of people attending hospital. But what is fascinating is that when you actually look at who has been attending A&E. There have been two peaks, people under the age of 25, many of whom are children, and the second peak is in the older age group. Of those in the older age group the majority are presenting with serious rather than minor health problems.
Our predicted daily admission is in the mid-30s but at the moment the figure is in the mid 40s. That means the equivalent of two whole wards have to be discharged every day just to keep the status quo. If that turnaround is not there then you don't have space for patients to come in.
Q Is demand for beds "unprecedented". Is this problem any worse this year than last? A Last winter we did have significant pressures. The difference then was the weather and we also had an influenza outbreak. But last year it was the younger sicker patients attending hospital, as opposed to the older sicker patients, who are attending this year.
The younger patients can be discharged home but the older sicker patients, once identified, might not have a care package as they need considerably more input from the social care sector to get them back in a position to be independent. The Norovirus outbreak, which happens every year, hasn't helped. When we have Norovirus on a ward we close it to any new admissions. We're unable to move anyone off that ward to anywhere else. Someone who is ready to discharge to a community hospital can't be moved. It's an airborne virus so staff get it, I've had it. It lasts 48 hours but you're not allowed back to work until three days after your last symptom, and you still have to make sure that ward staffing levels are adequate.
Q What is being done to mitigate the effect of these outbreaks which happen every year, and ease pressure on beds over the longer term? A One of the things we are trying to do is manage people properly so those with chronic illnesses, like COPD (chronic obstructive pulmonary disease) and diabetes, avoid coming into hospital in the first place with the right community support in place.
One of the projects we have is "enhanced care at home" and this is about supporting people who would normally have defaulted into A&E and into a hospital bed. We're also making more intensive care in the home by using nurse practitioners.
The sort of scenario where this could work is where an elderly couple are both coping. The husband has dementia but the wife gets a urine infection, that makes her confused. In the past the GP may have referred her to hospital but instead the enhanced care team is sent in that day provide that couple the support they need for two weeks to keep them at home. There is one currently in place in North Denbighshire and the scheme is being rolled out later this year in Anglesey, Meirionnydd and Wrexham.
Q What other steps could be taken to ease pressure on hospital beds? A The other thing we are looking at is managing end of life pathways. I think people should get the right to die where they want to die, and unfortunately we are in a situation where the majority of people with a terminal illness will end up dying in hospital.
We are looking at working with the enhanced care at home with colleagues on the cancer clinical programme group to make sure we can maintain people at home. The thing is all the evidence shows if you can prevent that first admission of someone with a chronic condition you delay significantly the chance of them ever been admitted to hospital. The problem is once people get admitted, no matter what you do, they always seem to get readmitted to hospital and that is especially true of people in the last few years of their life. They will spend up to 30 days in hospital and we don't want them there with the issues that we've got with infection. We all deserve a little bit of dignity and respect. Part of our problem is that we historically see hospitals as a safety, whereas we can deliver care, almost as easily, in a community setting.
Q Betsi Cadwaladr is one of the only health boards in Wales which looks like it will break even financially this year. Are the pressures on hospitals one of the consequences of making the necessary savings to do that? A Conversely no, because we have opened wards in Ysbyty Glan Clwyd and Ysbyty Gwynedd to deal with these pressures. Despite the fact that we are under huge financial pressures we have identified the need for more capacity we have recruited and opened 24 beds on both sites and we are looking at our bed capacity in Wrexham as well.
Q The Daily Post has reported cases of patients being left in ambulances for hours at a time, some even being triaged in hospital car parks. Why is this happening? A What we are seeing this year is a rise in the older, sicker adult. If you are an older sicker adult the chances are the way you get to hospital is via an ambulance.
As a consequence when you get lots of older sicker people coming in on ambulances, they come on trolleys, and they don't sit in chairs they have to be found (bed) spaces. So what we are seeing is a rise in the older sicker adult.
Q Are ambulance staff effectively being used as de facto porters with patients kept on trolleys because they can''t be transferred into a hospital bed? A At the moment we are putting in a huge amount of measures to deal with acuity (how nursing resources are allocated to deal with severely ill patients) and we are very aware of the pressure that we are facing.
Q Do you accept the knock-on effect this places on the ambulance service. Are you working with them to find a solution? A We have weekly meetings with the Welsh Ambulance Service to look at how we deal with these pressures. There will be conference calls and bed meetings where acuity is shared and we come up with escalation and contingency plans. That goes on seven days a week.
Q Is the board aware of the impact long delays and waits on trolleys have on patients and their loved ones? A I am very acutely aware personally of the impact this has, not only on the patient but on everyone else who deals with it, including the staff. You need to make sure that the patient and family are supported , and that they understand some of the issues that we are having to deal with. I've got huge admiration for our staff who go far beyond the call of duty at times to make sure patients are treated right.
Q One of the steps the board has taken to deal with unprecedented demand is to cut services and move staff from community hospitals. Bryn Beryl in Pwllheli being an obvious example. How do you think the board has handled this? A Around the community hospital changes, the communication was not handled well. The changes we made before Christmas, that came into effect around January 13, were emergency measures they were not planned, they were not part of our winter plan. We plan to reopen those wards which were closed as planned. They are temporary closures for three months, there might be some areas where we might have to delay but our plans are to revert to what was there before Christmas.
QDo you think criticism of the board''s lack of consultation on these changes is fair? What did you think of Gwynedd Council''s decision to pass a vote of no confidence on the way the board handled this issue? A I think its hard to say. My perspective was that something had to happen and quickly. The thing was that if it had been two weeks earlier we would have been able to have the discussions with our partners on that day. The question is who you tell first, our partners (like Gwynedd Council) or our staff. All we can do is apologise for any upset that we caused people.
QHave the closures worked, bearing in mind the anecdotal reports of ongoing issues, and is it sustainable (you''ve done it for the last two years) in the long term to cut services in one sector to fill a hole elsewhere? A We have to balance the relationship with community and safety. People are concerned about services that are precious and close to them.
QWhat is the board''s long term plan for North Wales' 22 community hospitals? We have 14 locality areas where we would like to develop the community hospitals as part of the community campus where they deliver a whole suite of services over and above what they currently do, such as providing x-rays, a blood test services, physiotherapy and so on. With an ageing population we do anticipate they will be used more acutely. We are looking at having more specialised beds, for example orthopaedic rehabilitation in Ruthin.
Q Is the proposal put forward for Blaenau Ffestiniog Memorial Hospital, ie no inpatient beds, a model for the rest of the region? A Well yes we could have hospitals without beds, because to some extent, we will have community campuses, where there will be beds that are not traditional beds, we are in part of a engagement process of what happens to primary care services but I don't want to guess the outcome of those and it would not be fair to do that before it finishes.
Q Can you give a guarantee that community hospitals will provide inpatient services into the future? A There is a role for community hospitals, the bed complement (across the region) is about 400 beds so it's the equivalent to a district hospital but we will be looking at how we use those beds and where we need them and also looking at the beds being in people's own homes.