MIDWAY through a bright autumnal morning at Ysbyty Glan Clwyd, Bodelwyddan, in its less-than-half-full emergency department (ED) waiting area, head of nursing Sali Williams warns not to tempt fate by breaking one of the hospital’s golden rules.
“Don’t say the Q word!” she smiles, having already seen too much in her seven months at Glan Clwyd to take anything for granted.
It’s a sensible stance to take, not least while such perennial headaches as COVID-19, staffing shortages, and demand outweighing discharges persist.
Life at Glan Clwyd began in March with a baptism of fire for Sali; on just her second day, Healthcare Inspectorate Wales (HIW) arrived to undertake a Quality Check.
After another on-site inspection in early May, what followed was damning. The ED was rated an area of extreme concern, while calls for Welsh Government to take urgent action were made.
“Targeted intervention” measures were introduced by Welsh Government, including addressing Glan Clwyd’s culture and leadership, monitoring vascular services, and deploying national clinical leads to the ED.
A further report in August, a month when Glan Clwyd was reported to have had 5,097 ED attendees with 44 per cent spending less than four hours there, declared that adequate arrangements were not in place to support the delivery of safe healthcare.
Yet if criticism has been as relentless as withering, heads haven’t been buried in the sand. There’s no blame culture at Glan Clwyd, and nobody denies mistakes have been made, but even if they were not for want of trying, it’s now about rectifying them.
“I think the focus has really helped us. When HIW first came, it was like a bomb had gone off,” Sali says.
“We were trying to scramble around with no resources, and without any thought. We were doing things in not necessarily the right way.
“We’re now very much focused on bottom-up; in the first few months, it was top-down, which doesn’t work, because there was too much dictatorship.
“We just needed more time to focus and work things out, and we can do it in small steps.”
Even as winter pressures begin to resurface, the mood now appears noticeably sunnier at Glan Clwyd than during the summer months.
One staff member tells of the marked improvement in atmosphere at the hospital of late, describing targeted intervention as “probably the best thing that’s ever happened” to Glan Clwyd.
These measures, they said, have not only brought everyone and everything at Glan Clwyd into sharper focus, but have provided the support and resources for the hospital to almost “reset”.
And for the likes of Sali, and site manager Amy Garnett-Williams, maintaining a calm disposition is just as pivotal for those they are responsible for as it is for themselves.
Even at 8.15am, as a shift which can span longer than 12 hours is barely underway, a ceaseless series of phone calls are punctuated by hollers of laughter from Amy and her colleagues; this morning, it is one staff member’s mispronunciation of numerous acronyms which proves the subject of much light-hearted ridicule.
But after six years in A&E and nearly two years as a site manager, Amy is embracing the additional pressures and responsibilities that her current role brings, all the while raising her young daughter as a single parent.
“We’re responsible for the whole of Glan Clwyd. Our job is patient flow from everywhere, and dealing with any issues, minute to huge, throughout the day,” Amy says.
“We’re the lead for fires and missing patients. It’s not just the ED for us, it’s all of the different clinics. Every day is different; you literally do everything.
“I really like this job when you see patients moving and in the right places, and when staff are happy and morale is better.
“Our team is quite perky and have great relationships with everyone, which is important in this job.
“We find that we’re having better relationships with the wards, who want to work with you, and who know we’ll go out and help them.”
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Behind Amy, a TV screen updating every minute reflects the sense that, as one hole is plugged, another instantaneously appears.
Not long past 8.30am, the screen reports 46 patients in A&E – “a really low number for this time of day - normally, it’s in the 70s and 80s,” with a healthy number of discharges – 24 –predicted for the day.
It’s not all positive, though. COVID-19 is back on the rise after numbers had diminished; one ward, for instance, has nine empty but unusable beds due to the coronavirus’ presence.
And during the daily site meeting, Amy reports that the hospital is currently at Level Four – the highest level of operational pressure – as well as there being 26 positive COVID-19 tests and, for a multitude of reasons, 13 bed losses.
At the Emergency Quadrant meeting, one ward is reported as closed, while another department’s longest length of patient stay is 12 days.
Multiple departments share that they are short of healthcare assistants, while another is full with patients, with no planned discharges.
“The focus from everyone is normally A&E, but as site managers, we get everyone contacting us to get patients into the hospital,” Amy adds.
“We’ve got 24 predicted discharges today, which is a high number for us, but it doesn’t reciprocate the demand.
“Our main focus is offloading ambulances, but we have to take into consideration every single aspect, because they’re coming in through every single orifice.”
Among the hardest tasks, not just for Amy and Sali but for all of their colleagues, is balancing high stakes against low numbers.
And though staff shortage is hardly an issue exclusive to Glan Clwyd – a report by MPs, published in July, found that 62,000 vacancies need filling by medical professionals across the UK – it is evidently one of the hospital’s most pressing concerns.
It is while talking to two of Glan Clwyd’s matrons, whose responsibility it is to ensure staffing is safe for every area, that the extent of this predicament is most laid bare.
“We work with each other, trying to cover whole areas, but it’s a challenge,” one matron says.
“Retention is difficult, because it’s been such a difficult time due to COVID. Staff are very tired and worn out.”
Though, there is hope that, through ongoing recruitment drives for such roles as healthcare assistants, for instance, staff shortages will slowly but surely subside.
Overseas nurses have also thrived; some of whom celebrated 20 years working for Betsi Cadwaladr University Health Board in 2021 having been recruited from the Philippines.
“The biggest pressure for us is obviously recruitment and retention. It’s not as enticing to work as a nurse, and for healthcare assistants, there are other jobs which are as competitive with pay,” another matron adds.
“If we can’t move patients out through the back door, if you like, then we have a blockage at the front door. We’re all working really hard, but it can feel relentless.
“What we need is an increased amount of student nurses, and some incentives; whether that’s pay-based, or for non-registered nurses to take up posts within the hospital; to increase our workforce.
“Then, everyone would feel their job is less intense, which would probably improve retention. That’s the cycle we’re stuck in at the moment.
“I believe they’re increasing nursing intake, but obviously, it takes three years for a nurse to train.
“We’re doing other stuff as a health board to fast-track healthcare assistants to do their training a lot quicker, and we’re starting to see people coming back to the wards which they went from as a healthcare assistant.
“We’re always looking for different ways to develop within work. Overseas nursing has been a good recruitment drive, and that’s ongoing. We are trying; we’re not leaving universities to do it all.”
And though Amy, meanwhile, feels that many of the hospital’s post-HIW changes have been beneficial, she would now like to see nurses given the ability to discharge patients from Glan Clwyd.
“There will be about 60 to 70 patients in hospital who are medically fit for discharge, and don’t need an acute bed; they’re just waiting for social care,” she says.
“But people are burned out, they don’t want to be carers, going into peoples’ homes for long hours on minimum wage.”
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A greater understanding among the public, Sali adds, of the different healthcare avenues available to them, may go some way to loosening the stranglehold on the ED.
Though, there is a conscious effort to educate, rather than criticise or blame, a fine line which the hospital must tread carefully.
“If we were standing here at 4pm, we’d have a queue (for ED) out of the front door,” Sali says.
“A lot of those will be waiting for call-back from their GP, or have waited for someone to come home from work to give them a lift in.”
Another staff member reasons that, if a patient can afford to wait hours, in some cases, to be taken to the emergency department, then there is likely no emergency to attend to.
Why, then, does the first port of call for so many seemingly remain the ED?
“It’s just historic,” Sali says. “People don’t understand what a minor injuries unit (MIU) actually does.
“For a dog bite, jellyfish sting, something in your eye, or a broken leg or finger, you could go to a MIU, where you’ll be seen to so much quicker.
“We had a patient who’d had a bite 48 hours earlier, went to a pharmacist who told him he needed antibiotics, so he thought he’d go to ED. But there was a six-hour wait at ED – if he’d gone to Holywell or Llandudno (MIUs), or phoned the GP, he’d have been seen to.
“We do try to ‘stream away’. We give them the numbers for the MIUs, and there’s supposed to be a registered nurse on the door who would be able to give immediate advice.”
And while winter will inevitably bring its own tribulations, it would be churlish to believe the summer brought much in the way of respite.
With holidaymakers and older generations invariably flocking to the North Wales coast for rest or retirement, perhaps it’s telling that any instance of positive COVID-19 tests reducing to single figures is seen as a minor victory.
“The longest ambulance has been at the ED entrance now for probably seven hours,” Sali adds.
“There are patients deteriorating while waiting at home for one, so their families say: ‘We’ll just have to take them’.
“They bring them here, at which point they’re really poorly, so we’re then getting sicker patients through the door.
“Or, you get somebody who has phoned with chest pain, but the ambulances are stuck here, so the patient comes in the car, and we then get a call saying: ‘cardiac arrest in the car park’.
“One happened the other week, where someone was on the trolley, doing CPR. That’s the risk we’re running at the moment.”
Inside, where wards are adorned with rainbow paintings and “Thank You NHS” messages, things certainly seem, if not calmer, then more controlled, than previously.
Corridors are not entirely patient-free, but extensive efforts have been made to bring them up to scratch since the HIW inspections – one staff member recalls an area being sectioned off overnight so that Estates could remedy it, describing the scenes as “like DIY SOS”.
As of the previous weekend, its SDEC (same day emergency care) unit was increased from a five- to a seven-day service, catering for between 40 and 60 patients who otherwise would filter into, and further overwhelm, the ED.
Its frailty unit was introduced at the start of 2022, aiming to provide older residents with the occupational therapy they may need, and return them to their place of residence within 72 hours.
A “START” rapid assessment area was also created following the May HIW review, where a senior doctor will hopefully be present to, in Sali’s words, “turn those patients around quicker”.
Rather than one substantial shift, there have been a litany of small yet significant changes; ramping up training and closing doors previously left ajar, to name a couple.
No longer are poorly patients left in inappropriate places, either, as Sali remembers once arriving to find one patient who had suffered an overdose, another who had had a stroke, and a third with severe abdominal pain, all with little or no privacy or dignity.
The paediatrics area, meanwhile, has been adapted and enhanced to ensure any child receiving care there feels far safer than before.
A particularly timely amendment, given one of the findings in HIW’s August report was that members of the public could enter paediatric areas unchallenged and without authorisation.
Pointing to a newly-built wall, where previously there was open space, Sali adds: “The children weren’t protected and at risk of adults potentially intoxicated, or with mental health issues, so one of the things we did was safeguard this area.
“We didn’t have a nurse allocated here – that was shared with minors. We try and do a 15-minute check, so nobody appears in the waiting room that we’re not aware of, so we’re constantly aware of what’s going on.
“There have just been little things, like putting a cupboard in for emergency drugs, adding a call-bell system and waiting room, decluttering, or ensuring doors which need to be closed, which were constantly wedged open, remain closed.
“Up to 76 per cent of our staff have done PILS (Paediatric Immediate Life Support) training now, whereas in May, it was about 10 per cent. We get training thrown at us, which is all really positive.
“We aren’t a paediatrics ED; we’re an ED which sees paediatric patients, so we don’t have 24-hour paediatrics cover. We’re doing so much training so that everybody is upskilled, and gets that basic knowledge of how to care for a sick child.”
And following HIW reporting that many staff said they felt unsupported from above, a unit manager is now in place, having stepped back from the clinical side to help staff, with more than 75 per cent of workers having had a one-to-one review in the last three months.
Overall, there is a sense that, after being engulfed by the pandemic for two years, staff are having to make up for lost time by learning on the job.
“People are trying to highlight issues as we go,” one adult nurse says. “We’re all adult nurses, but everyone has been, or is going on, PILS training now.
“Because of COVID, for two years, the resuscitation team didn’t have space to do training. Now, everything’s going in the right direction, and the department’s improving after two years of hell.”
There is a moment, after leading a warts-and-all tour of the ED, that one of Sali’s colleagues asks her, entirely deadpan, if she can “borrow your Welsh”; a small but pertinent reminder of the extent to which staff place their dependence on her.
And from both Sali and Lisa, whose roles bring the hefty demand of preventing staff morale from fluctuating from one extremity to the other, the same question elicits the same answer.
What’s the key to managing it?
“Be visible and approachable,” Sali says. “If there’s no visibility, there’s no support.
“Something will happen, and it will knock them. They’ve got to take the good and the bad.
“We have a Microsoft Teams chat, where I try and share it all, because they’ve got to see when we have negative feedback, and what that means. They’ve got to see what patients are complaining about.
“It’s about patient safety, but staff morale is so important, because you can’t get one without the other.
“It’s so important to get your staff on board. I’m very much a doer; if they ask for something, I’ll give them support, which makes a difference, because they feel like they’re being seen to.
“And because I’m not an ED nurse, I don’t know how to do their job, so I’m not telling them how to do it, either.”
“It’s just about being really visible and approachable, and building up rapports and relationships,” Amy adds.
“I’ve never had an issue of someone saying they’ve got a problem which they don’t know how to go about solving.
“All wards have their own in-house problems, and always come to site managers for advice.
“It’s just about being friendly.”
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