Why winter is such a worry

QWhy does PMH and the NHS generally suffer from winter pressures? What kind of problems do you face?

ADuring the winter period more patients are referred to us as emergencies who are thought to need admission by their GPs. In the main, these are general medical patients, many of whom will be over 65 who may already have a known illness which is exacerbated by the colder weather or influenza/respiratory infections around at this time of the year.

Together with this greater number of admissions, patients tend to be more ill and this lengthens the time that they need with us to recover from their acute episode. Both these factors cause problems due to the very high occupancy levels that the hospital works at, particularly in general medicine. In this speciality this means that of 100 beds only four would be vacant at any one time as patients are being discharged. This is too high a level and is common across the NHS (as found by the National Bed Inquiry) and does not allow a sufficient buffer to cope with the increase in admissions and length of stay.

In addition we may often find that we have an increased number of orthopaedic fractures as people slip in more icy conditions. If such patients are elderly then their discharge can be delayed while funding packages from agencies that have to provide care at home are put together.

QThe increase in patients during the winter is a national problem. How does PMH compare with hospitals of a similar size in tackling the issue?

AIn terms of our preparedness and the systems that we have for tackling the issue, then we are gaining credit nationally for responding swiftly and flexibly.

We have a number of schemes that prevent people coming through the hospital as more appropriate accommodation can be found, or speed up their treatment with specific plans helping us to discharge patients.

The difficulty is exacerbated here because there is a shortage of beds overall within the Swindon locality compared with say Royal United Hospital in Bath where in that part of Somerset there is the back-up of additional community beds.

We do not have this for the Swindon and Marlborough area in sufficient numbers. This is why we are in the process of opening up more beds to support the hospital. The delay in opening these beds recently caused us to have the problems where we were accomm- odating people in unacceptable conditions.

A natural response is to open up beds in other nursing homes but the other problem in this area is the lack of spare nursing home beds for us to buy as compared with other parts of the country. There are fewer private nursing homes available from which we could purchase beds for patients with NHS money. This limits the number of options available to the hospital and we are dependent upon colleagues in Social Services for developing and supporting this market.

QA plan to tackle the winter pressures was unveiled by Swindon &Marlborough Trust on Friday. Will any elements of this plan be launched early, to address the unseasonal increase in patients which we have seen last week?

AMany of the schemes that we described last week are dependent on additional staffing and it is not possible to turn this on just when we hit the crisis. So for that reason we are planning ahead and the majority of schemes will start in November ready for the increased pressure that we know we will face. In addition to these specific schemes there are a number of services already in existence which help us to manage more effectively a good example of this is the Community Rehabilitation Team.

QDiscussions about winter pressures have been taking place over a number of months with a range of agencies. What role do they play in the action plan?

AThe hospital doesn't act alone it is dependent upon and supports other services, ie GPs, community-based nurses provided by the local Community Trust, Social Services and other nursing homes. These organisations are all working together to co-ordinate additional schemes and priorities over the winter period and this is the responsibility of the Health Authority to co-ordinate.

As Primary Care Groups develop and will move into Primary Care Trust status, they are taking on this co-ordinating role to make sure that the additional monies we receive are used to best effect. Sometimes, when a person living at home reaches an acute crisis it is not always appropriate for them to be admitted to hospital.

If they do not have a medical condition which requires hospitalisation, alternative support can be provided, enabling them to stay at home. Or a patient could be admitted to other more appropriate facilities where they are stabilised and managed through their acute crisis. In those circumstances additional district nursing crisis support or availability of respite or convalescent beds are more important than the services which we provide. It is preferable to keep the hospital bed for the individual whose emergency is unknown and needs the diagnostic and treatment facilities of the hospital.

The role of the co-ordinating group is to work with all the other agencies to make sure that these services are understood by all involved and that when needed the most appropriate care can be given to individuals.

Key for us is also the ability to discharge patients at the rate at which they also are admitted through the A&E and Medical Assessment Unit. Other agencies play a fundamental role in supporting us in that function and so the availability of Social Services funding and packages and nursing home places is also critical.

QAre you happy with the level of financial support you have received from the Government?

AThe financial support that we have received this year has been greater than we've received for many years and the Trust itself has invested additional money. What we are now finding though is that physical capacity and staff are the scarcity, not the money.

Throughout the NHS it is recognised that building up the bed numbers and decreasing the occupancy levels which hospitals operate at is what is needed. That is why in conjunction with the PCG we are working on the increased numbers of beds outside the hospital together with additional services which support primary care and act as a better bridge between the hospital and GP/Community Services.

QPart of the winter pressures plan is to open 42 intermediate care beds in private nursing homes in the Swindon area. The new hospital at Commonhead will be supported by a network of 60 such beds. Will these be enough to support a growing population?

AThe winter pressures plan is to open 42 beds in the forthcoming weeks and also to construct the 60 bed unit at Commonhead. We have incorporated the increased population and increased referrals that will occur into our workload projections and this is one of the factors leading to the increased number of beds.

If we go on projecting into the future with always additional beds for additional population then we don't take into account the continuing practice changes that occur in medicine and the greater usage that such practices have of day surgery, outpatient procedures, drug related therapy, all of which are non-bed related.

Medical technology is changing ever faster and we will have to routinely check how such changes are impacting upon the resources that we will need to provide care. We do this every year when we forecast our activity needs in order to meet waiting list targets and also discuss changing practices with the medical and nursing staff. We will continue to do this.

QFunding has been found to increase the number of intensive care beds at the hospital from five to eight. The first of these will open in November, the second in December and the third in February. Why are they being opened in this staggered fashion?

AI would really like to be able to open them all as soon as possible, but ITU staff are highly skilled and trained individuals. There is not an immediate pool available within the NHS for the increased ITU beds that are being funded across the country.

Consequently staff have to be trained or recruited from elsewhere and this is slower than we would have wanted. We are opening the beds to the starting times of newly recruited additional staff. Given the individual attention that each patient needs, its not possible to stretch the existing staff across too many extra beds.

QAre there any other issues regarding the running of PMH you feel it is important to highlight?

AHospitals have never been able to act as stand alone entities as they are dependent upon a network of other services.

This is becoming increasingly so as patient characteristics change. By this I mean that more and more work can be done in day surgery, by 'scopes', by powerful new drug formats and in outpatients by using new technologies.

But, there is also an increase in the number of people living with chronic illnesses who are dependent on us for acute episodes, but long term dependent on GPs, district and specialist nurses and social services organised support.

The percentage of our beds occupied by patients who have these complex needs is increasing, so levels of provision and co-ordination with these services becomes more important, both for us to continue to function and for patients to get the care and support they need.

For this reason the NHS plan is placing great emphasis on developing these intermediate or bridging services and the answer, however simple or convenient, is not more and more hospital-based beds.

Locally, this is not even possible as within our existing sites we have no more capacity to open up, but of equal concern is the lack of intermediate capacity around us, compared with other health systems. This is taking time to build (literally) and commission and causes the problem which we experienced last week. We are now seeing these extra beds opening up.

Against this backdrop, the hospital is working at full capacity on its waiting times, both for outpatients and planned surgery. All our activity categories have increased, eg 13 per cent increase in in patient surgery which is bringing our waiting times down.

Similarly we have seen 11 per cent more new outpatients than at this time last year and our waiting times for a new outpatient appointment are steadily reducing.

We are doing this in a building which is outdated technically and has real bottlenecks which cannot be improved. For example, we are short of theatres and we have a mobile theatre available but this has its limitations.

We are receiving additional funding from the NHS and so we are able to recruit additional staff, but everyone knows that trained staff are in short supply and training takes time.

For this reason, some of the changes that the public want and we want to provide, takes time but all staff in the Trust are committed to seeing these improvements.

These are a sample of our objectives and I believe the Trust is making progress with these major issues. Many of our difficulties will be resolved in the new building but the service networks and the success of their operation are also key to the hospital's overall success.