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Comment by MichaelCollins | Hacker News Reader

> This isn't a collapse of emergency healthcare, it's a very predicted collapse of community social care: hospitals can't discharge if they need a care home place that doesn't exist. Without inpatient bed availability, ERs and AMUs can't admit to specialties and everything gums up at the front door.

How does that manifest as ambulance wait times? Do you think ambulance drivers are sitting around for an hour before responding to calls for help because... the hospital is full? That's like saying my train to the airport was late because the airport was full, it doesn't make much sense. How does one back up into the other?

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If you come to our local DGH's A&E in an ambulance and you're not a trauma or cardiac or stroke, you face seven to twenty hour wait in the carpark.

You will see multiple paramedics as they change shifts in situ.

In fairness the ambulance service has scaled amazingly well given most of their staff are now pegged in hospital carparks, but yes, waiting times for critical calls are extended, people are dying because ambulances aren't available.

All because they can't hand over to A&E. Because A&E can't ingest patients. Because wards can't discharge. Because care homes don't exist.

It's that simple. If you doubled the number of community care placements, staff, etc, you'd buy the NHS another ten years.

On top of that, it's also now significantly harder to get a GP appointment vs 2-3 years ago so more people are ending up in A&E instead. My own GP surgery has gone from offering "turn up and wait for an appointment" at set times 4 days a week (and call to book a day ahead otherwise) to "you can't do anything without booking in the online system and then the GP will call you at a totally unpredictable time 3 days later when you're not available" because they think its "better" (which I suspect means because it has cut GP workload).

Yes, The ambulances are waiting outside the hospitals with the last patient so they can't go to get the next one. Source: Family members have recently waited some hours outside A&E in an ambulance.

This is hard to believe. Just wheel the patient through the front door and let the hospital do the babysitting. There is no sense in using an ambulance as a waiting room.

The emergency department fills up because they can't find beds to admit people to. When the emergency department is full, there's nowhere for the ambulance patients to be put.

Just one of many, many stories on this:

https://www.bbc.com/news/uk-scotland-61395685

The patients are waiting in the ambulance because the waiting room is full, but I see your point. Why not just tip the patient onto the pavement outside the waiting room? I'm sure a full hospital with a full waiting room won't be to busy to sort that out.

> Why not just tip the patient onto the pavement outside the waiting room? I'm sure a full hospital with a full waiting room won't be to busy to sort that out.

Literally yes. Keeping them in an ambulance instead of the sidewalk won't get them into the ER any faster. And keeping the ambulance tied up at the hospital won't do any good for the next guy who has an emergency and is sitting on the sidewalk at the site of the accident either. At least if you move the injured people to the sidewalk at the hospital, the nurses can look outside and prioritize the worst. And the problem will be highly visible to the public, instead of papered over by using ambulances as waiting rooms.

What they're doing now is obviously prioritizing for appearances, not patient outcome.

Then you only rush to another patient who you can't treat either. Paramedics also need to hand off their treatment to hospital staff, if that doesn't happen then hospitals won't know what treatments were administered.

An ambulance is a portable "mini" ER room...

Using a parked ambulance as an ER room is gross mismanagement because the 'waiting room' for an ambulance 'ER room' is casualties spread across the entire city, such that the worst cannot be prioritized.

Even if the hospital's ER room has saturated capacity, moving all the casualties to the hospital waiting room as rapidly as possible still has utility because that allows the hospital to prioritize the worst, which they can't do if the worst is laying on the street a mile away with the ambulances all parked at the hospital.

I can promise you that the many smart people working in hospitals have considered this issue.

If someone is walking-wounded, they WILL be unloaded to sit and wait for 6 hours in a corridor.

The people who the ambulances are holding for long periods are those who are too sick to be left without attention. The paramedic staff continue to monitor them in order to escalate further if their condition deteriorates, and depending on the situation, medical staff from the hospital will be involved in this.

The ambulance staff obviously have a moral and legal duty of care, and can't just leave a seriously unwell patient on the floor outside the hospital entrance to get to the next call, which would likely be a patient no more ill than the one they just abandoned.

I’m happy that healthcare workers tend to be more empathic than what you are suggesting and will take care of patients end-to-end. You can’t load balance sick humans on the fly to achieve some optimal outcome.

Babysitting? These are patients deemed medically unfit enough to bring in. Who's looking after them after they're turfed out the ambulance? Every bed in every bay in A&E is occupied, each with an allocated nursing provision.

Oh we just double the number of nurses? Yeah, but no. They don't grow on trees. The current ones don't stretch (we asked). You can't just absorb 20-40 patients into your acute departments without space and staff. The paramedics are acting as those staff, their ambulances the space. Yes it's far from optimal.

I don't really see how patients so severely ill that they need a bed in A&E with dedicated nursing provision could be discharged into community social care, though maybe I'm missing something...

Discharge the less ill people, free up a bed for the more ill ones.

It's all about throughput. You're only looking at the front while the problem is in the back.

I think perhaps their point is that, if some of the patients not discharged are consuming a nurse budget that isn’t required (because they are healthy and can be discharged), then this nurse budget could be redeployed to those waiting in admissions. Not sure how reasonable this is, I’m sure the hospitals will have thought of it themselves. But it does seem particularly silly to have the paramedics stuck in place and unable to serve anybody who may be even more critically ill.

Hmm, this seems to have been attached to the wrong parent comment, and I am now unable to delete it ¯\_(ツ)_/¯

About a third of beds are blocked at our local DGH by medically fit people who still require community care provision. These are people waiting to go home (or to a home) from an inpatient stay.

Until they go, A&E can't admit people through to the beds they're currently in.

Even if you lie to the population and claim you'll add 7000 beds this winter, those beds aren't staffed. We can't surge 5000 nurses and 2000 support staff out of nowhere. They're all busy.

> Just wheel the patient through the front door

This is such a stellar use of the handwavey "just" that I feel we should have it bronzed.

> Do you think ambulance drivers are sitting around for an hour before responding to calls for help because... the hospital is full?

Yes, this happens - my grandfather attended with a head injury, and we were stuck in a side room with the ambulance crew (along with another patient and a second ambulance crew) waiting to do a handover.

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