Performance Watch: A sting in the tail?

It would be unwise to count any spring chickens just yet, because pressures from bad weather can cause problems well into March and April. Easter weekend and half term can be particular pinch points as it can be hard to get staff at those times.

Here’s my half term report on the health system’s winter so far.

As one central source close to the action put it to me this week: Staff are exhausted, there is no end in sight of the relentless pressure, but “the NHS can look government in the eye and say: ‘We did everything that could be expected.’”

Clearly there have been mistakes and significant problems. Four hour performance in December equalled the worst ever. As predicted in this column on 11 January, there was a slight improvement last month, but performance remains poor and high profile patient harm cases show a system under huge strain.

But that senior figure’s sentiment is fair. There is a justifiable sense of pride among those managing the winter effort, but no triumph. Instead, there are warnings about a potential sting in the tail, and observations that the fatigue factor felt across the system has been exacerbated by a sense that “everywhere you look there is another problem”.

And on that note – there are five key issues which will need attention in the winter wash up, both locally and in NHS Improvement’s “winter lessons” report, due in April. Here they are:

Collateral damage from focus on A&E target

System leaders’ desire to throw the kitchen sink at the four hour target over winter was understandable. But it has stored up problems in other important areas, including finances, elective waiting lists and mixed sex ward breaches.

NHS England estimated that its January moratorium on non-urgent planned inpatient appointments could result in up to around 50,000 operations being postponed. HSJ understands there is as yet no robust plan to reinstate the cancelled operations.

Meanwhile on the financial position, King’s Fund policy director Richard Murray – a former chief analyst at the Department of Health and Social Care, observed: “There is likely to be collateral damage to the financial position. We don’t yet know, for example, the extent to which trusts used the independent sector in January and there is anecdotal evidence that trusts were ignoring the agency cap rules to try and keep staffing levels safe.”

A review of data including on ambulance handovers

The last Performance Watch called for a transparent debate on the A&E performance data, after concerns were raised by the UK Statistics Authority.

Meanwhile, senior sources have acknowledged to HSJ there are significant concerns about ambulance handover delays data, a core metric in the weekly SitReps which receives significant media attention.

The issue was highlighted by the huge disparity in the number of handover delays registered by Norfolk and Norwich University Hospitals FT and the East of England Service Ambulance Trust’s own data for the trust this month.

The NNUH example is most likely at the extreme end. But system leaders have discovered data is not being collected in a uniform way across the country. Robust guidelines need to be developed to address this.

Bed capacity

The focus on flow, addressing delayed discharges and stranded patients will have freed up beds, but rising demand continues to gobble them up. Whichever way you cut it, after years of efforts to cut hospital beds, there is now a widespread need for more.

Bed occupancy has been consistently over the 92 per cent target all winter (and official data arguably underestimates it), while many clinicians believe the target should be 85 per cent.

A significant number of escalation beds (peaking at around 6,000 in addition to the circa 93,000 existing beds) were opened during winter, but this required cap busting agency staff, which cannot be afforded long term.

The system may not get the 5,000 additional beds the Royal College of Emergency Medicine says is required, but doing nothing is not an option.

A full investigation into ambulance delays

The East of England Ambulance Service Trust is under scrutiny for allegations that least 40 patients were “harmed or died following significant ambulance delays” in less than three weeks between mid December and early January.

The second meeting of the trust’s risk summit takes place on Friday (16 February). Fault almost certainly lies beyond the trust, as well as within, for these tragic episodes, and most likely beyond the NHS. Police and social services are also facing questions for their role in at least one of the deaths.

The preliminary evidence suggests systemic problems, which will not be addressed without a full inquiry.

Building on the success of the winter war room model

The assertion that the NHS was “better prepared than ever”, parroted from the prime minister downwards, sounded at times like a denial the system was desperately struggling to cope.

However central bodies should indeed be given credit for some meticulous planning and applying more rigour to system management this winter than in previous years.

Senior sources told HSJ that richer real time daily data meant problems were identified quicker this winter, and the centre was not behind the game when the weekly data was published, as had been the case in previous years.

The insiders said NHS England national operations director Simon Weldon and GE Healthcare Finnamore partner Neil Permain, drafted in on a short term contract to help run the winter war room, deserved credit for bringing operational rigour.

Both of these two are due to leave NHS England shortly, so ensuring these skills are present again next year will need consideration – as well as identifying improvements to what was a decent but not faultless operation.