Welcome to HSJ’s new Performance Watch expert briefing. Our new fortnightly newsletter will delve into the most pressing performance matters troubling system leaders and provide unrivalled insight into what they plan to do about them.
NHS England’s first weekly “winter situation report” for this year is published today, marking the beginning of what is feared could be a hugely difficult winter. So, how well prepared is the NHS?
National executives have repeatedly said, including in last week’s NHS England board meeting, that this winter’s planning process has been much more robust than previous years.
This prompts two questions:
1. Is this confidence shared by local NHS managers?
2. And, even if there has been an improvement, has it been enough?
NHS Providers’ new report, Ready and resilient?, published today goes some way to addressing the first question. It certainly backs NHS England’s assertion that winter planning has been (a bit) more joined up this year.
The trust lobby group said the work done by the team overseen by Dame Pauline Philip, the NHS national director responsible for winter planning, who, significantly, holds a post across both NHS England and NHS Improvement, had been “meticulous” and praised national leaders for beginning preparations earlier than previous years.
Trust chief executives were privately less complimentary. The main energy coming down from on high was a “sense of panic”, said one chief, and others bemoaned the completely conflicting demands from NHS England and NHS Improvement which continue to pile into their inboxes.
The sense of rawness after the controversial sacking of two hospital chief executives in September on the basis of their accident and emergency performance is still evident.
Chiefs report to HSJ that a slightly more cordial approach has been taken since that anger was expressed, although concern lingers that more P45s could be issued should the weather, and as a result performance, deteriorate.
But there is a hope that Team Philip could yet instill more alignment between the two national beasts on their winter messaging. One senior figure told HSJ that Dame Pauline, until recently a hospital chief, had gone to “significant lengths this year to streamline the winter performance reporting into a single daily report of an appropriate length”.
Reducing the reporting burden was one of 10 key recommendations made in NHS England and NHS Improvement’s review of winter 2016-17 report, published in July, which was carried out to underpin planning for this winter. I’ll come back to other recommendations later.
Other positives cited by the NHS Providers report were the £335m winter pressures fund (better late than never); the new national emergency pressures panel, to provide independent clinical advice; and wider roll out of streaming arrangements.
It would be a stretch to characterise any of these as complete game changers, but they are moves in the right direction.
Another potentially positive sign is four hour performance slightly better heading into winter this year: 90.1 per cent in October 2017, up from the 89.1 per cent in October 2016, although this could be down to data collection changes.
But there are key areas in which targets have not been delivered, such as bed capacity and delayed discharges, and areas which remain a serious and fundamental concern, like staffing.
Lack of NHS bed capacity (the number of beds in the NHS has halved over the last 30 years) is one of the overarching concerns trust leaders have this winter. NHS England confirmed at its November board meeting that the system had freed up only 1,035 beds against a flagship target of the 2,500 delayed discharges of care beds by September (recommendation two in the winter preparation report).
NHS Providers also pointed out there were 127,614 beds open in the second quarter or 2017-18 – 2 per cent less than the same quarter last year. Worryingly, overall overnight bed occupancy fell to 87.1 per cent in Q2 2017-18, although this was half a percentage point better than last year, NHSP said it meant there was “very little give in the system”.
Various workforce plans have been published, including for the A&E workforce, since last winter, but these are only likely to deliver in future years and staffing levels remain a major concern despite the problem long being a matter of public record. Some of the winter funding will likely go on locum and agency staff, but it will go nowhere near plugging the growing gap.
It would be unrealistic to expect system leaders to have solved the NHS’s staffing and bed shortages within a single year, but there has been genuine frustration about the lack of progress on delayed transfers of care.
One recommendation from the winter review on which a lack of progress would be inexcusable, however, is recommendation eight: “NHS England and NHS Improvement need to…present joint messages to the system, combining improvement resources to best support the system in the coming months.”
Wildly conflicting orders from NHS England and NHS Improvement ranked near the top of the biggest problems facing trusts this winter by delegates at the HSJ Summit and NHS Providers annual conference both held last month.
Of course, a nasty flu outbreak or long cold snap could derail plans. But better alignment of message is one of very few levers which NHS system leaders still have some meaningful control over this winter.
With battle lines drawn between NHS England and the Department of Health over what the NHS can and cannot deliver following the Budget, the scope for conflicting messages is high.
But the task facing trusts is already verging on Mission Impossible. Giving consistent central directions feels like a reasonable ask in the circumstances.