THE NHS is never far from an argument over the c-word – crisis – and we are in the midst of an almighty one over the state of emergency care. ANDY RUTHERFORD reports on winter pressures, fears over investment, and efforts to ease demand on frontline services.

THE NHS across much of the UK is, according to some, in meltdown, with chaos in the corridors of our emergency departments, and wards full to bursting.

January’s buzzword is “crisis”, with the Royal College of Emergency Medicine (RCEM) so describing the difficulties in emergency care in England, and a Welsh representative doing the same for Wales.

Even the Red Cross, not prone to declaring humanitarian crises on these shores, waded in with such a description of the NHS in England last week, provoking a sharp response from prime minister Theresa May, as the service resumed its familiar role as political football.

It is tempting to shrug one’s shoulders and say ‘we’ve been here before’ and certainly, there was a feeling of déjà vu regarding comments last week by RCEM Wales vice-president Dr Robin Roop. He warned: “Our staff are struggling to cope with the intense demands being put upon them and, more importantly, patient safety is being compromised during this busy time.”

Rewind almost 12 months and Dr Roop said: “Absolutely every emergency department is on the edge. We are ever so close to patients becoming really poorly in our departments.”

Winter pressures are a stark reality for the NHS.

Millions of pounds are spent annually on measures to meet predicted extra demand, be they opening extra hospital beds, boosting resources at the point of discharge to ensure patients can go home in a timely manner, or running schemes – such as Gwent’s Falls Response Service, described elsewhere in this feature – to prevent admissions in the first place.

But every year there comes a point, in January, February and/or March, where the word “crisis” is uttered, as demand rises, emergency departments and hospital beds fill up, and operations are cancelled.

Aneurin Bevan University Health Board – not alone in Wales – asked people during January’s exceptionally busy first week not to attend the Royal Gwent and Nevill Hall Hospitals’ exceptionally busy emergency departments unless it was absolutely necessary.

It urged people to consider alternatives such as NHS Direct Wales, their local pharmacy, their GP, or a minor injuries unit, based on their symptoms.

That plea continued last week, and will apply for the foreseeable future. It is, logically, a message people should consider at all times, given that up to 40 per cent, possibly more, of emergency department attendances are deemed unnecessary.

A more rigorous and considered approach to seeking help for our ill health or injuries would undoubtedly help, but would that solve the problem of pressure on the NHS?

Maybe in part, but it is unlikely to be a complete solution.

With an ageing population and thus increasing emergency department attendances for people with a complex range of current and underlying problems, demand continues to grow, particularly in winter.

Add ongoing difficulties with recruitment and retention of staff in an under-pressure – and some say under-funded – NHS, and it is little wonder that at this time of the year, the seams begin to split.

The NHS inside and beyond Wales is under “immense and unrelenting” pressure – and at the heart is a need for investment to need demand, says Wales’ top nurse.

But Tina Donnelly, director of the Royal College of Nursing in Wales, believes this is a matter for the UK Government, initially, to address.

“The NHS is under immense pressure. Demand is outstripping resources, and it cannot continue,” she said.

“The bottom line is that demand across the UK is outweighing the resources available to deal with things in a timely manner.”

She added: “There are staff shortages everywhere, but that is one of the reasons we have campaigned and now have safe staffing levels (legislation) in Wales.

“That is making a difference, and is something maybe the other UK nations need to learn. But still we have staff finishing shifts and returning to work soon afterwards to help colleagues, and that is not sustainable.”

Ms Donnelly told the Argus the funding question is “for the UK Government to realistically look at on a four-nation basis” and cited the difficulties facing the Welsh Government, which spends approaching half of its annual budget on health and social services.

“The NHS in Wales is creaking, and clinical staff and managers are doing their best to cope with unprecedented demand,” she said.

“I don’t think it is conducive to public confidence to use the word ‘crisis’ – to me, that would be for instance where you couldn’t even get nurses to come on to do shifts.

“But it becomes quite challenging every year to thank staff who are under pressure 24/7 and if it continues without resources I cannot see people saying we are not in crisis.”

Ms Donnelly cited a need for more nurse and healthcare support worker training places, despite two years of 10 per cent increases in Wales.

“But the NHS here is still 2,500 places short. Couple that with vacancies in primary and community care, and care homes, and it is around 3,500.

“There’s not a short term solution. The Welsh Government does not have the money from central government, and England is in a worse place, at 24,500 nurses short.”

She said the removal in England of the nursing bursary, has been followed by a 25-30 per cent reduction in student applications. It has been retained in Wales, at least for this year, but the future is uncertain.

“Wales listened (regarding the bursary) but the Welsh Government does not have the money. That is a central government – and a taxation – issue,” she said.

She added: “This is a National Health Service that needs to be dealt with properly, and this should be the government’s priority across the four nations.

“The pressure is unrelenting. There’s no respite, and that is why a large number of people are seeking to leave or retire early.”

There are many initiatives, ongoing or winter-targeted, that the NHS in Wales and across the UK employs to try to ease demand, be it on emergency departments, hospital beds, or ambulance services.

In Wales, the Choose Well campaign is a key component of efforts to minimise unnecessary attendances at emergency departments, with people urged to consider seeking alternative advice and treatment, from such as NHS Direct Wales, their local pharmacy, their GP, or a minor injuries unit.

Concern has been raised in some quarters that Choose Well does not work, but public service union Unison backs the campaign in Wales, and Darron Dupre, its ambulance services lead in Wales, believes it needs more funding.

“I’ve had conversations with the RCEM and a few consultants, who have said ‘when are you going to admit that Choose Well doesn’t work?’” he said.

“My opinion is that it hasn’t been properly invested in by the Welsh Government, there has not been enough public sector buy-in, and we as a union have effectively taken on quite a lot of that responsibility.”

He added: “The Welsh Government budget for Choose Well is £45,000 a year. That is peanuts. It needs more investment to help get the message across.

“We talk to our members and to non-members on a daily basis in hospitals, and we’ve asked people about Choose Well. I find that if you engage with people the message gets across, but it takes time and you need more face-to-face engagement.

“All parts of the system are feeling the strain, and Choose Well has a role to play in helping educate people.”

Among a myriad of schemes designed to ease pressure on hospitals in winter and other times of the year, is the Falls Response Service currently being trialled in Gwent.

Run by the Welsh Ambulance Services NHS Trust and the health board, it involves a team comprising a registered paramedic and a physiotherapist, with a specially equipped vehicle, who provide falls victims who are either uninjured or have a minor injury, with a full medical and social assessment.

They can also arrange for care at home appropriate to patients’ needs.

Eighty per cent of the 229 patients attended during the first 11 weeks of the six-month trial were treated at home without needing to go to hospital.

Project leader James Gough added that, of those who had to go to hospital, half were admitted through medical or emergency assessment units or other departments, avoiding A&E.

“It’s an exciting project that has benefits for patients, emergency departments, and the ambulance service,” he said.

The team operates 8am-8pm, seven days a week, from Blackwood ambulance station.

Health board director of therapies and health science, Alison Shakeshaft, said the service, funded through Wales’ intermediate care fund, was set up with winter pressures in mind, but may have a valuable role to play through the year.