Unscheduled care in NHS Grampian – The Aberdeen Royal Infirmary ‘front door’ services.

Situation

The Emergency Department (ED) at the Aberdeen Royal Infirmary has been under significant pressure to deliver its service in the face of staffing and operational issues. The difficulties experienced within the ED are not confined to that department. They extend to many other clinical services involved in the delivery of unscheduled care close to the hospital ‘front door’ including; Acute and General Medicine, Acute Paediatrics and Acute Geriatrics.

Background

The difficulty of providing a hospital based emergency ‘front door’ service is a national one. The common themes reported across the UK include the design of emergency services, the dependence on ‘middle grade’ trainee doctors for service critical roles, staff recruitment and retention, funding, capacity and demand with poor flow from admission to return to the community. The Aberdeen Royal Infirmary (ARI)faces all of these issues but is particularly challenged around the ability to rapidly recruit to support acute and chronic staffing shortfall.

Assessment

The ED in the ARI is critically dependent on a middle grade workforce that will not be sustainedby recruitment through the national training scheme. The UK fill rate for this grade is 29% and locally this is no different. Flow of patients from the ED ‘front door’ is hampered by hospital capacity release early in the day and intensified by interdepartmental delays in accepting patients when the respective services are also under pressure. The ARI ED service assesses patient groups that could be more appropriately managed by other specialists. The services such as ‘Hospital at Night’ that support out of hours new admissions as well as current inpatients are also dependent on a middle grade trainee workforce and need strengthening. Our acute services have responded to the challenge of delivering appropriate care against the 7 day 24 hour demand but they are not yet fully configured to match this profile of need and activity. We need to bring all of these issues together to formulate a single vision of how ARI acute services will develop and operate together to meet this challenge.

Recommendations

The board is asked to consider the following recommendations and reports:

  • Notethe current staffing position within the Emergency Department.
  • Consider and approve the attached plan to enhance and stabilise front door services to Aberdeen Royal Infirmary.
  • Note that a rapid service improvement initiative to further shape and support the patient pathway of care for unscheduled presentations will be conducted in November, with the appropriate consultation in advance.

Dr Nick Fluck 29th September 2014