The emergence of urgent care issues reflects not only the problems within the health service but patients’ inflated expectations of hospital services, writes Robert Royce

For much of my career everyone was clear what a “major incident” was.

It was typically triggered by an external event (accidents or explosions, for example) and, if internal in nature, it was due to an unforeseen catastrophic event, such as a fire or a flood.

Robert Royce

Robert Royce: The system’s current state must not become business as usual

The above are rare events. Typically they involve trauma of some kind and as such, arguably have a bigger impact on surgical specialities than the physicians.

Everyone – staff, patients, politicians, public and the media – understand what this type of major incident is and hence the “rules of the game”.

Adrenaline rush

A lot of staff actually enjoy major incidents because they are an adrenalin rush, and “saving lives” is what they entered healthcare to do.

It’s absolutely not “business as usual”, although often the numbers treated turn out to be little different from a normal day, even by the surgical teams.

I have experienced two such major incidents. The first was caused by a chemical leak at a factory in South Wales, and the second by a gas explosion in London.

‘This is the world of “gold command” and “designated action cards”’

Two memories still make me smile: the first is of a hospital administrator and his team desperately trying to speed read the major incident documentation; and the second, the unhappiness of a medical director after discovering that most of the hospital’s consultants were not actually in the building. This was London in the 1980s and many were probably attending to their private practices.

This is the world of “gold command” and “designated action cards”, and over the years the NHS has got better at organising itself for such eventualities.

Internal affairs

However, what we are increasingly hearing about – via local networks and media reports, rather than official statistics – is the emergence of a somewhat different category of major incident called an “internal major incident”.

Talk about an internal major incident to those steeped in the protocols and language of emergency/contingency planning and you often get a dismissive response.

“No such thing,” they insist. “You’ve either declared a major incident or you haven’t. If you have, then all the protocols apply. These internal major incidents are what hospitals often used to call ‘serious internal events’.”

‘We are no longer that clear about what a major incident is’

There is a mix of pedantic insistence of terminology here and a genuine point.

We are no longer that clear about what a major incident is… or what we are supposed to do about it.

The term is psychologically bound up with “extreme events” and sudden crisis.

However, what we are now witnessing are hospitals’ bed positions deteriorating over time – sometimes measured in hours, others over weeks – to a point where “there is no room at the inn”.

The accident and emergency department silts up because there is no movement to the wards, but patients continue to arrive.

Hospitals are in crisis at that point, but that crisis is somewhat akin to the latter stages of congestive cardiac failure; you can’t get the output the body needs to sustain functioning. More patients are coming in than going out.

The new norm

Given the deteriorating state of the four hour target across the country this is neither a new or rare event.

Why then should this state of affairs be increasingly generating a declaration of a major incident?

‘More patients are coming in than going out’

I think there are two main reasons. The first is in response to that traditional enemy of acting in the appropriate way to an unacceptable state of affairs: habituation.

When the A&E is full up and there are no beds it is not business as usual, but what happens when this feels like it is?

I worked at a trust for a number of years that went for months at a time in with a status of serious internal event. In the end it meant no practical difference. That’s habituation.

In truth, you can’t expect staff to take what are deemed to be exceptional measures, if that then becomes the norm.

Risking criticism

The second driver behind the spike in internal major incidents is the fear of criticism from regulators, especially the Care Quality Commission, about an inadequate managerial response to a situation that is putting patents “at risk”.

Declaring a major incident unequivocally shows third parties you are taking the situation seriously. It also gives more leverage in getting those third parties to undertake actions that will get patients discharged/transferred from the hospital.

The increasing frequency with which major incidents are being declared is a symptom of a system slipping out of control. Hospitals are struggling to get any kind of balance between emergency admissions and discharges.

‘It’s a symptom of a system slipping out of control’

Attempts to do so take up more and more time. The opportunity costs that are being generated by management and clinical teams doing little more than fire fighting every day are enormous.

Most trust deficits and staffing problems are directly bound up with having many more beds open than their financial plan allows.

Would be patients attending A&E who could be treated in primary care (or self-care) get a lot of media and policy maker attention, but they are typically not the major problem.

People in A&E who should be seen in primary care don’t get admitted.

Great expectations

Instead, what we are doing is both admitting a significant number of patients where it is not clear what an acute hospital is going to do that will change their prognosis, and also failing to get patients out whose care needs do not require them to be in an acute hospital.

This is not only a health system problem but also reflects the inflated expectations our society has about what can (and should) be done in hospitals.

‘This problem reflects the inflated expectations our society’

These patient types are increasing in number and will continue to do so. Hospital beds are not.

If we don’t want internal major incidents to be subject to the same habituation process every other escalation status the NHS has devised, we had better figure out very quickly where this type of patient is going to be cared for instead of the hospital and get them in place.

Dr Robert Royce is an independent healthcare consultant