Winter always has been and remains a challenging time for any NHS trust in many ways. But despite seeing similar levels of flu cases as 2017/18, rising demand and more and more difficult decisions to make about priorities, broadly speaking, at Sherwood Forest have had a better winter than last year.
But what does a better winter look like? For the trust, it has felt calmer, performance (access) has improved on the elective and emergency care pathways, ambulance handovers have improved, patient care has remained safe and staff morale has been good. That said, it has felt tough all the same, and we need to thank our staff right across the trust for their hard work and resilience.
Why so tough?
- demand for both A&E admissions and attendances have been higher this year – in some specialties 10% higher admissions than the previous winter, 25 more resus/majors patients per day
- the trend differed to previous years and it felt longer – December wasn’t as busy as it had been, but April was one of the most difficult months (and we hadn’t changed our winter capacity)
- vacancies and staffing pressures mean we have had to make difficult choices about priorities, as we only have so many colleagues to look after patients
- our colleagues across the trust have had to work as hard as they ever have.
But what does a better winter look like? For the trust, it has felt calmer, performance (access) has improved on the elective and emergency care pathways, ambulance handovers have improved, patient care has remained safe and staff morale has been good.
Our performance from October 2018 to end of March 2019 has been 93.0% and last year over the same period it was 89.5% for emergency care. Our RTT performance has remained above 90% with very little on the day cancellations linked to hospital reasons. We have halved ambulance delays over 30 minutes and they are now less than 10% - we still have more to do. Our staff engagement score this winter was 3.91, which is our best ever, 11th best in the country and the best in the Midlands.
How have we achieved this?
Before we get into what we did – we are lucky in many ways. Our wards have 50% side rooms helping us manage infection - we have a strong urgent care system both within the hospitals and in the community – with a primary care 'front door'. We have a positive culture amongst our colleagues who always put patients (whether their specialty or not) first. Finally, our emergency department is broadly fully staffed with substantive nurses and has had successful recruitment to additional consultant posts in recent months.
Our wards have 50% side rooms helping us manage infection - we have a strong urgent care system both within the hospitals and in the community – with a primary care 'front door'.
That said, I feel we were better prepared for this winter. Our preparation began in spring 2018 when we held a series of listening events with colleagues across our three sites to understand how the previous winter had felt and what we could be doing better. The overall view was, we know winter 2018/19 is going to be busier than winter 17/18 but we need to do some different things that will make it better for patients and our colleagues. From the listening events, a series of options were identified which were then tested to see if they were realistic in terms of staff and cost, acknowledging a plan that involves recruiting lots of staff is unlikely to work.
While a lot of this work took place internally, we also worked very closely with our health and local authority partners. We knew that for us to have a successful winter, it would involve our partners having a successful winter too.
Our winter plan was signed off by our Board in August 2018, which gave us plenty of time to communicate it and plan its implementation. We opened an additional 35 beds compared to winter 2017/18 – but this involved contracting with some local intermediate care providers, converting a surgical ward to a medical ward, and opening a small number of additional acute beds.
While on the whole, I feel we have improved things for our patients this winter, I recognise that the real story of winter is the resilience of our staff. Despite lots of successful recruitment, we have 15% vacancy rates at band 5 nursing levels and this limits what extra capacity we can open. We never change our nurse to bed ratio as safety remains our number one priority. The conversion of surgical capacity to medical capacity works well, but it can often lead to more acute patients being concentrated on other surgical wards which puts them under additional pressure. Our day case unit is particularly busy during winter as we try to keep as much planned operating going as possible. Our trainee and staff grade doctors, particularly in medicine have a lot more patients to see and we boost their rotas to support them. Finally, our emergency department, the part of most hospitals that doesn’t have a fixed capacity, has had a challenging winter with an average of 25 more majors/resus patients to look after a day (the work of three to four doctors and nurses per day). We have had to, with partners, put in additional resources to support the department.
While on the whole, I feel we have improved things for our patients this winter, I recognise that the real story of winter is the resilience of our staff. Despite lots of successful recruitment, we have 15% vacancy rates at band 5 nursing levels and this limits what extra capacity we can open.
The relentless nature of the winter pressure has a cumulative effect on staff, most colleagues can deal with a tough day or shift – NHS professionals are some of the most resilient I have ever seen – but when those shifts are nearly every shift for months on end it tests their resilience. Once again I want to thank our staff and our partners for their dedicated and compassionate care through these times.
Our planning for winter 2019/20 is now underway. Our debrief has started and we will listen to our colleagues about what worked well and what could be better. Crucially, we will continue to work with our partners as part of our local integrated care provider to ensure patients get to the right setting to meet their care needs.