COVID-19: the catalyst for change in emergency care

Deputy Chief Inspector of Hospitals, Heidi Smoult, discusses hospital emergency care services, our work with a group of senior emergency department clinicians, and the importance of applying the learning from coronavirus

As the coronavirus outbreak gathered pace, health and care staff across all roles and services stepped up to meet the challenge of the crisis head on — demonstrating resilience and embracing new ways of working. Their collective efforts delivered a remarkable response to one of the greatest global health emergencies in our history. For the first time ever the NHS had to stop the majority of its non-emergency services and the need to adapt quickly to manage demand and keep people safe became imperative.

The introduction of lockdown restrictions brought with it a marked decline in the number of Emergency Department (ED) attendances by non-COVID patients. This gave greater flexibility for ED staff to change the way they operate, separate COVID-19 patients from others, put more experienced clinicians at the “front door”, and work more closely with other hospital teams to improve patient flow.

We also saw greater use of NHS 111 by the public, ambulance crews treating an increasing number of patients at the scene, and an impressive digital transformation by many primary care services to harness the benefits of remote consultation and support people in the community. In some cases, the closer system working that has been so desperately needed for some time was brought about within a matter of weeks.

As lockdown is gradually lifting and EDs and other NHS services start to face an increasing level of non-COVID demand, we must act now to review what has worked well and apply that learning. This needs to happen before any second wave, and before we reach winter when the usual seasonal rise in other viral illnesses is likely to create even greater challenge.

This is a view that we know is shared by frontline NHS staff. Over the last three months we have engaged regularly with a group of senior clinical ED staff from hospitals around the country to understand the pressures they have faced, and the steps being taken to manage infection risk, adapt to social distancing rules and ensure the best possible care for patients. They have shared their concerns about the impact that increased footfall through hospitals will have, as more routine services resume and the need for non-COVID care ramps up — yet the virus remains a risk.

They are already seeing an increase in the number of patients in need of mental health services visiting the ED, leading to more psychiatric referrals. The predicted rise in mental ill health in the wake of the pandemic has been widely documented and ensuring appropriate and accessible mental health provision will be critical if the right care is to be available to those that need it.

Separately, consultants have highlighted the need to ensure adequate emergency care provision for children and young people. There was a significant decline in the number of presentations to paediatric EDs during the peak of the outbreak. Children are less likely to become seriously ill with the virus, but lockdown restrictions and families choosing to stay at home are other possible contributory factors. As a result many paediatric EDs were moved to “temporary” locations — often not designed to function as a paediatric emergency facility — in order make space for adult services and fulfil social distancing and infection prevention control requirements. As the level of demand for children’s emergency care returns to pre-COVID levels and plans for the winter respiratory season begin, it will be vital to ensure any longer-term reorganisation of paediatric emergency services does not impact on the quality of care or patient safety.

Collectively senior clinicians are also clear that the current focus on robust infection prevention and control must be maintained and that efforts to strengthen alternative routes of access for lower acuity patients should continue. This is going to require more of the collaboration we have seen between acute, community and primary care and between teams and services within individual hospitals.

Coronavirus hit the UK as NHS services were emerging from a challenging winter during which hospitals grappled with heightened demand and continued workforce pressures. In this context we saw growing concern around the safety of some EDs due to the impact of overcrowding and the increased occurrence of corridor care. The Royal College of Emergency Medicine (RCEM) is absolutely right to say that we cannot return to how things were before — having overcrowded emergency departments and lengthy corridor waits for patients is not an acceptable option if we are to protect against the further spread of the virus. The factors that have helped maximise capacity and keep staff and patients safe during the height of the pandemic are crucial to maintaining safety going forward.

There is no doubt that balancing treatment of COVID-19 with routine and emergency care will bring significant challenges, with the need to retain social distancing adding further complications — but the events of recent weeks have shown what is possible and what can be achieved. The commitment, skill and flexibility of staff working across all parts of health and care are the key reason why services have not been overwhelmed. As staff continue in their efforts, they need the support of senior leaders, regulators and system partners to help them build on the progress made so far towards greater collaboration and consolidate those new ways of working that have proved so vital in the fight against the virus.

CQC is continuing its work with ED clinicians to help understand what lessons can be learnt from the impact of the pandemic. In the coming weeks, we’ll be sharing more of that insight to support hospital trusts and the wider system to lock in long-term service improvements and use COVID-19 as a catalyst for change.

You can also read our blog from Chief Inspector of Hospitals, Ted Baker on harnessing transformational change in emergency care and across the wider health and care system