Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter delves into the most pressing performance matters troubling system leaders and provides unrivalled insight into what they plan to do about them
The damage done to the NHS by the arrival of the wicked weather dubbed “the Beast from the East” this week is yet to be fully quantified.
But what is perhaps more worrying than the potential consequences of the great Siberian chill is how hot the system was running even before the freezing cold snap arrived, revealed by data published yesterday.
NHS England’s latest weekly SitRep report said bed occupancy was up to more than 95 per cent, way above both safety targets (the NHS England’s 92 per cent target and the Royal College Surgeons’ 85 per cent) in the previous week.
This was the highest this winter, despite over 20 per cent more escalation beds (averaging around 5,000 on top of a hospital bed base of around 95,000) in place than the same time last year, NHS Providers said.
NHS England is seeking to point the finger of blame for high bed occupancy at, among other factors, bed days being lost to:
(a) Flu: which it claimed was “the worst in a decade” (Public Health England said 2011, the year of Swine Flu was in fact worse, but I understand this has been the worst in terms of “seasonal flu”); and
(b) Norovirus: which it said had resulted in diarrhoea and vomiting up 143 per cent higher on the same time last winter.
The national commissioner said up to 4,000 hospital beds a week are still being taken up by flu sufferers, and on average over 950 beds were closed, up from fewer than 500 for the same week last year, because of D&V.
The combined 5,000 bed figure taken out by Flu and Norovirus (circa five per cent of the total hospital bed base) is coincidentally exactly the same amount of beds that the Royal College of Emergency Medicine has been saying is needed to shore up the system.
The inconvenient truth of course is that staffing, financial and physical constraints make the prospect of a raft of new hospital wards by the next winter highly improbable.
With many, including the Royal College of Surgeons this week in HSJ calling for winter planning for next winter to begin now, it would be fair to assume that squaring this circle on the capacity question will loom large in the debate.
The flu and norovirus spikes are of course on top of all the other flow issues caused by a high number of patients staying longer than usual, because of what are thought to be higher general levels of acuity this winter.
Two categories for long stayers were created this winter: stranded patients (seven days or more) and super stranded (21 days or more), the numbers of which have remained stubbornly high since winter began.
With beds in short supply and the centre’s (justifiable) winter focus on the four hour target, elective work has been subject to mass cancellations. As highlighted in Performance Watch two weeks ago the NHS is likely to face a sting in the tail after winter (if winter ever ends).
And I understand there are no robust plans in place to reinstate the tens of thousands of cancelled operations, a number which will have ballooned after more cancellations across the country this week due to the weather, to date.
Of course, the grand plan for addressing capacity has long been to cut the numbers of patients ending up in hospital in the first place, a key plank of the Five Year Forward View. But the National Audit Office’s report on emergency admissions – which also came out this week – however concludes NHS England’s plans to take pressure off hospitals and reduce admissions with better care in the community had largely “stalled”.
The report says that while emergency admissions growth “has slowed slightly there is limited evidence to show that NHS England’s programmes [including the urgent and emergency care and vanguards programmes] have brought about that slow-down”.
The report does however praise the NHS for reducing the impact of rising emergency admissions “largely by reducing length of stay and growing daycase treatment”.
It concludes: “The NHS also still has too many avoidable admissions and too much unexplained variation. A lot of effort is being made and progress can be seen in some areas, but the challenge of managing emergency admissions is far from being under control.”
Another interesting component of the issue is around the surge in “zero day admissions” which drove two-thirds of the growth in emergency admissions in recent years, according to exclusive HSJ analysis published this week.
The rising proportion of zero-day admissions is the subject of discussion at the highest levels of national bodies, which are trying to determine how many are necessary and whether providers are being paid appropriately for them.