For months, potentially even years, there have been conversations about whether the NHS is at breaking point. Patients are waiting in ambulances outside A&E for hours, sometimes days, to be seen; health boards in Wales have declared critical incidents due to 'unprecedented demand'; and thousands are on waiting lists for operations.
One leading doctor said that this winter has proved "significantly harder" for the Welsh NHS than other years, telling the BBC, that pressures on staff were "tremendous" and that they were suffering "moral injury". Hospitals have recently been advised to discharge patients who are well enough, even if a care package is not ready for them.
WalesOnline spoke to Judith Paget, the Director General of Health and Social Services and Chief Executive of NHS Wales, about the issues facing the health service at the moment - and what exactly is being done to tackle the problems we are currently seeing. This is what she told us.
READ MORE: This winter is 'significantly harder' for the NHS than other years - leading doctor
Ambulances queuing to hand over patients outside hospitals for hours, and sometimes days, has become common across Wales. This can’t be good for patients, ambulance staff or 999 response times. What are you doing to address this?
"Yes, absolutely. It's not good for patients. It's not good for ambulance response times. We've been seeing the delays increase over the course of the pre-Christmas week and over the last week. The pattern of presentations into the NHS has been quite different this winter than it has been previous. In previous years, our hospitals tend to reduce their occupancy as we go towards Christmas Day and we see more beds available. But, this Christmas, because of the Covid and flu surge that we had the week before, we actually went into the Christmas period with incredibly high numbers of bed occupancy and 800 more patients in our hospitals this Christmas Day than we did last year.
"This has affected our ability to cope with a surge in demand that we've seen, and it has absolutely led to increased delays. This week, we've been on full escalation working with health and social care colleagues across across Wales to try and work to make sure that we de-escalate the situation, try and ensure that our ambulances move to handover in a much swifter response. But, also that we see the response times into the community being much improved. It's slowly having an impact.
"Today is a better day than the last couple of days. In fact, today's a better day than we've had for probably the last two weeks, but [we're] not complacent about that because we've still got patients in ambulances outside the emergency department - not so many and not waiting for so long - but we have to continue to work on that.
"One of the things we've done is to suggest that maybe patients who are at the lowest risk in our hospitals, who are medically fit and ready to be discharged, will now get discharged so that the patients with the highest risk (i.e. those on the ambulances, or those in the in the community waiting for an ambulance) can come to hospital. [There’s] lots going on lots of activity. [We] absolutely want to make sure that we resolve this situation. The combination of Covid and flu and the surges in demand that we've seen over the last week-and-a-half, two weeks have been incredibly challenging for the NHS."
You’ve taken the decision to release patients back into the community before a care package has been arranged. Are you concerned there are still huge risks involved?
"I think this is about balance of risk. This is about us using our hospital beds for the patients who are at greatest risk. So, that will be the elderly person who's had a fall at home and is on the floor waiting for an ambulance to arrive, or the elderly person who has had a stroke and is in an ambulance outside our A&E departments.
"The balance of risk in the system, as suggested by our professional colleagues or senior nurse and senior medical staff, is that the balance of risk is out of kilter at the moment. We really need to discharge some of our lowest risk patients in order to make way for the highest risk patients that we're not getting. So, is there a risk? The letter that has gone out from the chief nursing officer and the deputy chief medical officer is incredibly balanced in its approach. It doesn't say, ‘We'll just discharge people and don't worry about it.’ It gives a whole host of mitigations about how we can make sure that discharges are safe. It's very clear that this to be done when it's safe to do so.
"What we're seeing over the last couple of days is a really fantastic response from families when our nursing staff are ringing them to say, ‘Mum can come home, we've got a package of care, but it's not going to start for another 48 hours. Could you help by supporting them until the package of care starts?’ The response from families has been very positive. Is there always a risk? There's always a risk, in everything. This is about balance of risk and trying to minimise the risk to the most concerning patients."
Are we paying the price for reducing the average number of hospital beds in Wales through the closure of smaller hospitals over the last 30 years and could we bring back the extra capacity we had during Covid?
"The hospital beds that have been reduced are those related to planned care. As we've moved to do more day surgery, we haven't needed so many surgical beds. The beds that we use to treat the medical emergencies on the sort of demand we're getting at the moment have not reduced. There have been reductions in some of the beds used for mental health patients as well. We're not being affected by that in any way.
"In terms of some of the things we did during the pandemic, we brought retired members of staff back to work. We've seen some staff come back to join us over the last couple of weeks just to help out, particularly in places like critical care. We did deploy field hospitals in the past, but our staffing resources are quite challenged at the moment and our ability to staff those would be very difficult.
"We're using care home capacity. We've commissioned 500 additional care home beds from the independent sector. We're working with the sector to see if it's possible to commission more. In fact, in some ways, we've commissioned more beds through that than we would have had provided through the field hospitals in the pandemic as well. So, [there are] lots of things going on, but just different things."
Thousands of people are waiting years for elective operations. It’s been mooted that one way to deal with the backlog would be to have specialist centres for the likes of hip operations. Is this something that has been considered and could you tell us more about the thinking around that?
"There is work going on across the health boards on a regional basis to think about what opportunities there are to come together to work together to develop what you call specialist centres. Particularly, the areas that people are focused on are eye care or eye surgery, possibly some endoscopy or diagnostic centres, and orthopaedics. Those discussions are fairly well advanced. They're at different stages in different regions.
"Whilst those are coming to fruition, clearly we're still building capacity - so, additional capacity going in places like Cardiff, the Prince of Wales Hospital. The minister is actually there today, I think, visiting a new facility there. We're not sitting back and waiting for the big solutions. We're actually thinking about how we can build incremental additional capacity while we work through how we might deliver those bigger centres that that you mentioned."
An NHS consultant in Wales, Peter Neville, has recently said that the NHS is on the verge of collapse as the demand for healthcare is rising faster than funding levels - do you agree?
"I think the matter of funding and policy is a matter for ministers. I think we have seen increased investment in the NHS in Wales over a number of years. Clearly, the NHS will always use additional resources and make requests for additional resource. I think this is about a balance of how, in the case of Wales, Welsh Government determines to allocate its resources and probably a question for ministers, not a question for me.
"But, I think there's something about the way in which we use the resource that we've currently had. We've got a commitment to continue to train more staff, which we are absolutely committed to. I know Peter Neville will have talked about the need for more training, more staff, and I absolutely agree with that. That's why we're focusing every year on increasing our commissioning numbers, getting more people through training, going overseas, where we can, when we can't recruit locally. So, [there is] a huge focus on additional resource and additional staffing for the NHS."
With the current issues - bed capacity, A&E waiting times, waiting list backlogs, staffing issues - what is the priority that you feel needs to be fixed here?
"I think it's about the system, so I think it's really difficult to call out one thing. I think the NHS is a system, it works as a system. I think our focus is on things like the urgent and emergency care system through our six goals for emergency care plan. Clearly, planned care is really important. We've got a plan to recover our planned care capacity, and also workforce planning as well.
"We've got a strategy, and the Minister is hoping that she'll be able to launch a workforce implementation plan very shortly too. I think workforce, urgent and emergency care, and planned care are key in that. But, there’s a whole host of priorities for the NHS - what we do with genomics, how we develop research capacity in NHS Wales. There's a whole list of things about how we can change what we do, plan for the future, think about how science and technology can help us deliver care differently, how we can innovate.
"The list of priorities goes on and on and on, to be quite honest, but the focus at the moment is about recovering from the pandemic, making sure we support our communities, address some of the inequalities that have been shone a light on since the pandemic, but also do all that recovery, urgent and emergency care, planned care, recovery and workforce development."
Peter Neville also said that demand across the NHS has increased over the last 15 years, but, given what we have discussed, is it at all possible to say that the NHS today is functioning today as well as it did 15 years ago?
"I think it's difficult because the NHS now is quite different to the way it was 15 years ago. I think there are still things we can change and improve. Clearly, our population is getting much older, which is a great thing. We can do more to support people, we can manage more disease, we can care for more people, we can treat more illness, which is absolutely fantastic.
"We need to think about the broader community support how our integrated teams work, how we support primary care, how we continue to invest in primary care, and how we make sure we work alongside social services, the third sector, and housing to actually develop our services in the community as well."
What needs to be done to make the NHS in Wales more sustainable?
"I think the NHS needs to change and adapt in response to continuing science, technology, innovation, but also to make sure that it continues to focus on its workforce and supporting the well-being of staff as well."
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