The NHS has learned much from the demand surges of other winters. But while effective measures are in place, costs are significant and challenges for managers still persist
The NHS has just come through a major surge in winter demand. Although this also affected staff and led to unprecedented levels of 999 calls and accident and emergency attendances, it has not led to the headlines and air of crisis of winters earlier this decade.
“Equipping frontline staff to navigate a complex local system is a challenge”
It is worth reminding ourselves how bad the crises were: extensive bed blocking, very long trolley waits, patients being driven around the country looking for beds and Mavis Skeet dying as a result of having her operation postponed four times. In December 2000 The Times wrote: “As sure as Christmas, the ritual of the ‘winter crisis’ is built into the British calendar. It is also built into the fabric of the NHS.” It was right.
The situation has since significantly turned around. Once regarded as a separate project, winter planning is now part of normal business and although this winter arrived early and hard the NHS has been able to respond quickly. The usual measures - added beds, extra GP opening hours, extra community services, weekend lists and postponement of elective surgery - have been put in place as well as a revamp of systems for discharge, rerouting patients and co-ordinating bed management.
However, dealing with winter peaks in demand is potentially getting more difficult. Since 2000 there has been a reduction of more than 13,500 beds. As length of stay has fallen at an even faster rate, in theory there has been little loss in capacity. In practice, however, because demand is not evenly distributed, a smaller bed pool will be less resilient in dealing with peaks in demand.
Second, much more attention is now given to ensuring patients with infections are cohorted and sexes not mixed, also reducing flexibility. The four hour A&E wait target, 18 week referral to treatment target, cancellation policies and the ambulance target of 75 per cent of category A calls taking eight minutes to arrive all take away safety valves. There is little space for dealing with peaks in demand and no room for error.
Worse still, the targets can conspire against each other: a blocked A&E can result in ambulances being unable to offload, with obvious knock-on effects in ability to meet response times.
There is also a concern that managing these targets may have a negative impact. Trusts are concerned about the imposition of penalties through the contract or performance management routes.
It is clear these targets will not be relaxed, but we would hope for a measured and proportionate response to breaches, with a sensible approach to penalties that avoids the tendency for the major achievement of dealing with a difficult period of high demand to be obscured by a debate about minor deviation from targets.
Problems in A&E are often a direct consequence of difficulties elsewhere in the system, especially the ability of hospitals to safely discharge their patients. This means the ability of the local health community to operate as a system is crucial, but that is hard to achieve.
The number of relationships that have to be developed and the task of equipping frontline staff to navigate a complex local system creates a significant challenge.
Community beds managed separately from the main acute bed pool are sometimes not as actively managed as they need to be. Fragmented services and specialist teams are hard to co-ordinate. This is a particular issue in primary care, where the number of times they are used is relatively low. The larger size of ambulance service also makes co-ordination with local services that are operated and commissioned at PCT level challenging.
The pressures have been contained but not without price. Additional beds and agency staff rates cost enough to hit the front pages. The costs of buying surgical capacity, additional home care and ambulance staff overtime are also significant.
Meanwhile there seems to be unfinished business in ensuring emergency care networks are as effective as possible. While a number of the local next stage review visions aim to reduce A&E attendances through provision of alternative facilities or improved triage, evidence for this being easy to do is not encouraging. In many cases these alternative services encourage additional attendances.
The transport of “GP urgent” cases also needs attention to remove incentives to just call 999 and to end the tendency for these patients to arrive in batches. All of this is a significant management task.
There has been a clear long term trend of increasing demand. While this has slowed slightly, we are still uncertain what is driving the growth. But it seems difficult to claim that the policy of shifting care is being particularly successful in this area.