A&E Perspective: Easing Lockdown, NHS Backlog, No Respite for EDs

A beautiful sunny long bank holiday weekend happily coincided with the beginning of the easing of social restrictions in the UK. This enabled many families and friends to reconnect and socialise in their gardens for the first time in many months and it appears that the Government's current roadmap out of lockdown is working, so far. 

The latest figures from the ONS demonstrate that the number of infections appear to be falling, although the rate of decline has plateaued, and this is probably due to schools reopening and the increased social interactions associated with it. We can surely anticipate that the rate of infections may increase further in the following weeks as the restrictions are lifted but this risk is being somewhat mitigated by the exceptional success of the vaccine rollout and hopefully some improvement in the Government's incredibly expensive outsourced track and trace system. It is somewhat disheartening to see the increasing number of infections in mainland Europe, and fears regarding new strains of COVID-19 that may reduce the effectiveness of the vaccine remain real. From a personal point of view the idea of allowing foreign holidays appears to be an unnecessary risk.

There have been discussions regarding the NHS recovery as we put this peak of the pandemic behind us. Even before the second lockdown the damage that the first wave of COVID did to NHS waiting lists was significant - and was worse than expected - with 4.4 million people waiting for care. This position will have worsened even further as trusts struggled to maintain elective activity during the prolonged second wave of COVID.

NHS Backlog

Thoughts are already turning to waiting lists and it is likely that an already exhausted workforce may be asked to take on extra work. Prior to the recent budget, Royal College of Emergency Medicine's (RCEM) President Katherine Henderson called on the Chancellor, Rishi Sunak, to honour his promise to deliver "whatever extra resources our NHS needs", and highlighted that 45% of emergency medicine (EM), anaesthetic, and intensive care doctors reported psychological distress, which was far in excess of the general population, as well as calling for a significant expansion in consultant numbers and an additional 4000 whole time equivalent (WTE) emergency nurses.

This plea appears to have fallen on deaf ears as the Government attempts to deal with the economic fallout of the pandemic and record levels of public debt. In the background there is much disquiet about the Chancellor's failure to address the pension's issue and possibly exacerbate it by freezing the Life Time Allowance until 2026 as well as a proposed pay rise of 1%. I wonder whether there will be the appetite for consultants and other staff to, once again, go the extra mile, particularly as there will need to be a period of recuperation for many staff groups after the most challenging 12 months.

Emergency Departments

This brings me onto what is currently happening in emergency departments. Many trusts are already back to 'pre-COVID' numbers of attendances and although the number of COVID patients has dramatically fallen, the amount of 'normal' emergency department work has returned alarmingly quickly. The RCEM's Winter Flow project cites 71,722 attendances, which exceeded the previous highest weekly total set at the beginning of the project in 2015. The Winter Flow publication also draws attention to the declining performance against the 4-hour standard by 0.86 % and an increase in 12-hour stays to 2209.

It seems there is unlikely to be any respite or chance of recuperation for the emergency department staff. RCEM also welcomed the priorities that were laid out in NHS England's operational planning guidance, and it is pleasing to note the prominence given to supporting the health and wellbeing of staff and recruitment and retention, although it would appear the previously mentioned freezing of the pension life-time allowance (LTA) will do little to encourage senior clinicians to continue working and may even bring forward retirement plans. It remains to be seen whether they are able to ensure that NHS 111 will be adopted as the primary route to access urgent care as this would require a significant shift in behaviour of those that attend the emergency department 'inappropriately'.

Mental Health

There appears to be a much greater number of mental health related attendances, with significant numbers of self-harm and serious overdoses. This is perhaps explained by the ONS study published in August 2020 which stated that almost 1 in 5 adults were likely to be experiencing some form of depression during the coronavirus pandemic - almost doubling from the previous pre-pandemic year - and some charities are claiming that up to 10 million people will need either new or additional mental health  support as a result of the pandemic. One can assume that these numbers are likely to have increased even further following the latest prolonged period of lockdown. The mental health teams attending to these patients who have presented to the emergency department seem overwhelmed and under-resourced for the current level of demand, and it seems that the Government's pledged extra £500m spending on mental health services is long overdue. Emergency departments remain a very unsatisfactory place of safety for these individuals during a crisis.

Anecdotally, there also appears to be a large increase in alcohol-related problems, which doesn't bode well for those emergency department staff that are unfortunately scheduled to be working when the pubs and other hospitality opens fully on 21 June. Undoubtedly the numbers of attendances are going to increase in the coming weeks, as social interactions increase and the population returns to work. We can anticipate an increase in the number of accidents and injuries requiring medical attention, and I'm sure I'm not the only emergency department doctor not looking forward to this part of the 'return to normality'.