The must-read stories and debate in health policy and leadership.

A stark warning from north London

Given the unseasonably warm temperatures so far this month, you could be forgiven for thinking winter wasn’t coming and autumn was here to stay. But events at the Royal Free hospital in north London this week suggest winter may have arrived after all. 

The first critical bed shortage of the season spurred the major acute trust to declare an internal incident. It cancelled all surgeries except cancer operations and had consultants double checking every patient, ensuring everyone in a bed needed to be there as the focus was “on discharging patients safely to free up capacity”.

Some HSJ readers have questioned the newsworthiness of this episode, pointing out that such incidents are common in today’s NHS. Yet this is the first high profile one to come to light this year, and comes at the sometimes-fêted Royal Free, with one of the busiest emergency departments in England and one of the highest turnovers too.

Last week, NHS England deputy chief executive Matthew Swindells said the single biggest focus for winter preparations was on beds, specifically freeing up and opening them to allow for a better flow of patients out of the ED. NHS Improvement reiterated the message in a letter to trust chief executives on Wednesday.

With the weather in the capital fearsomely mild, the travails at the Royal Free perhaps bodes ill for the capital’s capacity come a cold snap.

Why are we waiting?

NHS leaders can’t seem to decide what to do about the elective waiting list.

Elective care was deprioritised a couple of years ago when the big financial incentives were placed solely on the four hour emergency target.

Then new money was offered in the 2017 budget, and a commitment made for the waiting list to be “no higher in March 2019 than in March 2018”.

But since then the list has continued to grow – from around 4.1 million to 4.3 million in Septemberprompting a drive in the summer to ensure hospitals met the target.

This has even gone so far as NHSI handing a list of 54 trusts that might need support to private sector providers, to make them aware of the opportunities.

Whether this results in a big splurge of outsourcing remains to be seen, though. Sending 200,000 extra cases to private hospitals could cost around £400m to £600m, which would threaten to tip NHS expenditure well over the permitted edge in 2018-19.