Winter crisis? What crisis?BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5203 (Published 13 November 2017) Cite this as: BMJ 2017;359:j5203
- Nigel Hawkes, freelance journalist, London, UK
Winter provides a test of NHS resilience, each year foreshadowed by evermore claims that this time there really will be a major breakdown. No winter since 2012-13 has passed without warnings of crisis, each year’s predictions more apocalyptic than the last.
Yet the NHS has managed to survive so far. The Care Quality Commission, England’s health and social care regulator, last month reported that the quality of care is mostly good and improving overall.1 Public satisfaction has declined from its 2010 peak, when 70% of respondents declared themselves very or quite satisfied, but in 2016 it still stood at 63%—“high by historic[al] standards,” says the King’s Fund.2 Is the public blind? Is the NHS indeed on the verge of collapse, unseen by those it serves?
Last month, the annual warnings from health chiefs began in earnest. NHS Confederation chief executive, Niall Dickson, said there was “an even greater sense of foreboding this year than last,” echoed by NHS England chair, Malcolm Grant, who said: “We face winter better prepared than we have ever been but more scared than we have ever been.” Andrew Foster, chief executive of Wrightington, Wigan and Leigh NHS Trust, tweeted: “A perfect storm of funding and workforce shortages vs an abundance of patients.”
Although these warnings of a winter crisis are widespread, the doomsayers never specify how we would recognise one if it happened. The NHS is not going out of business like Monarch Airlines. Crisis is the wrong word since it implies an event that, once overcome, is history. The process is really more akin to slow strangulation, with winter tightening the ligature.
“More will die”
The result is not the sudden disappearance of care but the slippage of targets and increasing safety risks, neither of which may be immediately apparent to patients. Taj Hassan, president of the Royal College of Emergency Medicine, says that last winter a large proportion of hospitals were dealing with less than 80% of patients within the four hour emergency department target. “We know from many published studies that this creates a heightened risk of safety being compromised and patients being harmed,” he says. “More will die, and more will come to harm.”
Tim Gardner, senior policy fellow at the Health Foundation think tank, says the system of operational pressure escalation levels (OPELs) introduced last year to replace hospital black alerts showed great variation across the English NHS, with some trusts under much greater pressure than others. “The pattern of OPEL levels three and four would flare up and then die away,” he says. “The lights weren’t all flashing red across the board all the time.”
Alarm about winter pressures has prompted some extreme proposals, such as discharging patients into people’s spare rooms to overcome the lack of social care places or preventing walk-in patients accessing emergency departments unless they have first consulted their general practitioner or NHS 111. Both ideas seem to have been killed at birth after attracting national publicity. The time is not yet ripe for solutions this radical.
Even if walk-ins were prevented, it probably wouldn’t help. The winter problem (increasingly the year round problem) is not the numbers turning up at emergency departments but the ability of hospitals to manage the flow of patients through the system. In a report on last winter,3 NHS Improvement and NHS England (NHSI/NHSE) said that attendances actually fell by 1.7% compared with the previous winter, yet waits increased. “These delays are largely caused by poor patient flow through and out of the hospital,” the report concluded.
The report made 10 recommendations to better prepare for this winter. Some are exhortations—“a renewed drive and focus to implement best practice across all systems”—but a few are specific enough to put to the test.
For example, the first recommendation is that bed occupancy should be more actively monitored and actions taken to ensure it remains below 92%. For most of last winter occupancy levels exceeded this, peaking at 98% on 25 January 2017, despite trusts opening 4200 extra beds.
So achieving below 92% occupancy will be a massive challenge, even though NHS England’s national urgent and emergency care director, Pauline Philip, says that plans are already in place to open at least 3000 extra beds. The latest figures, for the first quarter of 2017-18 (April, May, and June), show bed occupancy running at 89.1%, almost exactly the same as in the first quarter of 2016-17 (89.2%). This is 2.5 percentage points higher than the average for 2010-15, and there is no evidence of improvement.
The cause is not more patients arriving but fewer patients leaving. For years the NHS has enjoyed a favourable streak in which rises in admissions have been balanced by reductions in length of stay. Between 2001 and 2013 emergency admissions rose by 3% a year on average, yet emergency bed days rose by only 0.2% over the entire period, figures in a recent NHS England board paper show.4 Since 2013, the tide has turned and lengths of stay have increased by 1.8 million bed days, a 6% rise in four years.
The main reason is delayed transfers of care, which have risen steadily and increasingly swiftly since 2014. Reducing delayed transfers was a key recommendation in the NHSI/NHSE report, the aim being to free up 2000-3000 acute beds.
Is this much needed improvement happening? In August this year, the most recent month for which data are available, 5809 beds were occupied in English hospitals by patients whose discharges had been delayed. Although this is marginally lower than the 6060 reported in the same month in 2016, the difference is insignificant. NHS England admits that “to date, only limited progress has been made” in reducing delayed transfers. Chris Hopson, chief executive of NHS Providers, the membership organisation for trusts, says more bluntly that the plan has failed.
Gardner sums it up: “The aim was to get the proportion of occupied bed days down from 5.6% to 3.5%, roughly where it was three years ago. That amounts to making up three years’ change in a few months, and it’s going to fall some way short.”
Local authorities blamed
The finger is being pointed at local authorities. Delays attributable to social care are fewer than those where the blame lies with the NHS but are rising more swiftly, both in numbers and as a proportion; 37.3% of the delayed transfers in August 2017 are laid at the door of social care, compared with 33.5% the year before.
The government promised local councils an extra £2bn (€2.3bn; $2.6bn) to ease the strain but told them in July that the money was linked to performance targets, amounting in some cases to a 70% cut in delayed transfers, which the County Councils Network described as undeliverable. Some 32 councils with high rates of delayed discharges were told in a letter from the health secretary, Jeremy Hunt, and communities secretary, Sajid Javid, that if progress wasn’t evident by September they stood to lose their share of the new money.
Another specific recommendation in the NHSI/NHSE report was the need to remedy workforce shortages in primary care and in urgent and emergency medicine. NHS staffing statistics do show some rises in staff classified as working in emergency medicine. In June this year (the latest figures available) there were 1648 consultants and 1751 specialist registrars so recorded, against 1486 and 1594 in June 2016.
NHS England announced a year ago that there would be extra money to boost GP numbers, but the statistics do not show any clear sign of this proving effective. Comparisons between years are difficult because changes have been made to the way the data are collected, but the message is that although the GP headcount may be rising slowly, the numbers of full time equivalent GPs are not.
Another key to navigating winter, say NHSE and NHSI, is getting the planning done early. A common feature of published plans, as in every winter, is postponing elective operations to free beds for emergency admissions.
At Maidstone and Tunbridge Wells, for example, almost all elective work will be halted at the Tunbridge Wells site and, in a move unlikely to provide much reassurance, mortuary capacity will be increased by 100, possibly by installing a mobile mortuary on site. At Portsmouth Hospitals, where meeting the four hour emergency department target is a distant dream (in August it was met for only 74% of patients), the chief executive, Mark Cubbon, plans a six month reduction in elective work to try to get things right, even though this will reduce income.
Similar expedients have got the NHS through recent winters, though some say that luck has played a part. In 2014-15, mortality soared but nobody much noticed at the time and similar trends were seen across Europe so blaming NHS winter pressures seems unjustified. The most likely cause was a poor match between the circulating flu virus and the vaccine.
Estimating how much damage flu could do this winter is largely guesswork. Despite some headlines, Australia’s flu season, just coming to an end, has not been especially bad. Laboratory confirmed cases are up sharply, but new rapid testing introduced this year makes comparisons with previous years difficult. Clinical severity has been low to moderate, the Australian Department of Health says, and the vaccine seems to be a good match with the circulating virus.
Given that the NHS has so far survived the annual prophecies of doom, are these misplaced? Gardner does see dangers in focusing too much on the short term. “The NHS does need to do winter planning,” he says. “But it also needs to think how it’s going to deliver services better in the future, and there are lots of good examples. But these changes take a very long time—you can’t just cut and paste them from one area to another.
“In worrying about meeting winter pressures, the NHS shouldn’t forget longer term changes. It has to do both.”
“Each winter is an exacerbation of a downward spiral”
Taj Hassan, emergency medicine consultant at Leeds Teaching Hospitals and president of the Royal College of Emergency Medicine
“Over the past five years the NHS has been on a steady downward spiral. During each autumn and winter we get an exacerbation of this spiral.
“There’s a combination of things that makes our departments very crowded: increasing demand, increasing complexity, and the steady decrease in acute beds. What’s made it worse over the past two or three years is that the amount of money for social care is also declining.
“Last year was the worst in 15 years. If you look at us now, the four hour standard as we enter the winter is as bad if not worse than it was last year. So this year potentially could be worse—even [NHS England chief executive] Simon Stevens is saying that we could be 3000 beds short of what we need.
“We’re very lucky that NHS staff always step up to the plate, but we’re facing certainly one of the toughest winters for the past 15 years. We absolutely need to unblock delayed transfers of care, so we need more social care packages in the community, we need more acute beds.
“The workforce issue in emergency departments is acute—the NHS is spending £1.3m a day on locums. A new workforce strategy we’ve just agreed with NHS England, NHS Improvement, and Health Education England aims to establish more permanent substantive posts.5 The fact that we have got the three most senior execs of the NHS to sign up for this is a real positive.”
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.