Intended for healthcare professionals

Opinion

How can we relieve current pressures on NHS hospitals?

BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2815 (Published 16 November 2021) Cite this as: BMJ 2021;375:n2815
  1. Chris Ham, co-chair1
  1. 1NHS Assembly

We should learn from previous local initiatives and ensure they are sufficiently resourced, writes Chris Ham

The unfolding crisis in health and social care took a turn for the worse this week with the release of a report by the Association of Ambulance Chief Executives on the unprecedented pressures in urgent and emergency care.1 The Association’s analysis demonstrated that patients are being harmed by delays in handover between ambulance services and hospital clinicians, resulting in “a position that is totally unacceptable to all involved in patient care.”

Publication of the report coincided with news that the Secretary of State for Health and Social Care, Sajid Javid, is establishing a “war room” focused on improving NHS performance.2 The war room is being advised by Michael Barber who led the Labour government’s work on public service reform under Tony Blair. Barber’s extensive experience will be tested to the limits at a time when all parts of the health and care system are working at full stretch and new targets are likely to be counterproductive.

Urgent and emergency care is in the eye of the storm as hospital emergency departments respond to high levels of demand and struggle to admit patients because of delays in discharging those who no longer need acute care. These delays have many causes among which lack of social care support and residential and nursing home provision are of growing importance. Hospitals are increasingly reliant on “corridor care” as patients wait for a bed to become available and this in turn slows down transfers from ambulances.

What happens before patients enter the urgent and emergency care system contributes to the growing sense of crisis in the ambulance service and emergency departments. Challenges here include difficulties in patients accessing support from general practices because of the pressures GPs are under, gaps in community health services and social care support in people’s homes, and unevenness in the provision of intermediate care. Lack of appropriate alternatives to attendance at emergency departments mean that hospitals often become the carers of first and last resort.

Delivering care more effectively and appropriately requires all parts of the urgent and emergency care system to work together to care for patients in the right place at the right time. Targets for ambulance handover times, or waiting in emergency departments, may have an impact, but what matters for patients is their experience of the whole system. This is much harder to affect because of the complexity of the system, the interrelationship of its parts, and the difficulty for those overseeing performance of knowing how and where to intervene.

In looking for answers, the team in Sajid Javid’s “war room” should learn from previous initiatives designed to address these challenges. An early example was work in Torbay in south-west Devon to improve care for frail older people and in so doing to reduce demands on hospitals. Beginning in 2004, integrated health and social care teams were established in each locality, working closely with general practices and focused on responding rapidly to the needs of the vulnerable patients they served.3

Improvements in care were facilitated by pooling of health and social care budgets. This resulted in funds that were nominally meant to be spent on NHS care being used to increase the availability of social care. As a result, it was possible to provide more care in people’s homes and reduce use of hospital beds. Importantly, use of residential and nursing home care also fell, and delayed transfers of care from hospital reduced to a negligible number.

Critical to Torbay’s success was recognition of the vital role of intermediate care which integrated care teams were able to access directly instead of through a formal referral. The focus was on rapid interventions to meet acute needs and to restore the confidence and capability of the people supported in this way. Response times were short and availability increased over time to an extended working day and weekends. Some of these gains were difficult to sustain in the context of organisational reforms in the NHS, financial pressures on the local authority, and changes among senior leaders in the NHS and local government, but the lessons remain relevant today.

The benefits of integrated working are also evident in Mid-Nottinghamshire’s integrated care transformation programme, one of the vanguards set up following the NHS five year forward view. The programme put in place several interventions including a 24/7 care navigation service, intensive home support, an acute home visiting service, and enhanced care in a care home setting. An independent evaluation showed that these interventions were associated with reduced use of hospital services, although this did not become apparent until the end of the six year period studied. The implication is that it takes time for new services to become embedded and demonstrate results.4

Politicians and their advisers would do well to heed this warning while also learning the lessons from Torbay, Mid-Nottinghamshire, and other areas that have bucked the national trend. Integrated health and social care in the community has the potential to offer an effective alternative to hospital admission, but only if it is properly resourced. Intermediate care that is available rapidly in response to crisis can enable people to live independently at home with support and must be provided 24/7 wherever possible.

The government should play its part by ensuring that funding for social care is both adequate and sustainable. The spending commitments announced recently are welcome, but in the case of social care fall well short of what is needed. Different entitlements to health and social care also create barriers with means testing of social care a factor in delays to patients being discharged from hospital.

The government must also work with employers to develop the workforce capable of providing care in this way. As an example, a key innovation in Torbay was the use of health and social care coordinators able to draw on the skills of all team members and to arrange care packages for people in need. Coordinators did not have formal professional training, but made an essential, and relatively inexpensive, contribution to innovations in care. The greater use of paramedics and the St John’s Ambulance to care for people in their own homes should also be encouraged.

In his book on public service reform, Michael Barber enumerates several common errors in large-scale system reform.5 One of these is failing to invest in capability, capacity and culture change, for example by not giving priority to training the workforce of the future. This is already the principal rate limiting factor in efforts to improve health and social care and will continue to be so until fully funded and credible workforce plans are put in place. If the war room can help the government avoid this error, it will have performed a valuable service.

Footnotes

  • Competing interests: Chris Ham is co-chair of the NHS Assembly and non-executive director of the Royal Free London Hospitals NHS Foundation Trust. He writes here in a personal capacity.

  • Provenance and peer review: not commissioned, not peer reviewed

References