A re-assessment of NHS priorities is necessary to cope this winter

Another September, another potential winter crisis suddenly appears on the horizon. Such is the lot of the NHS manager, returning from summer holidays to be pitched into planning for the cold months ahead. Health secretary Frank Dobson has written to chairs diplomatically congratulating them (again) on how well they handled emergency admissions last winter, and making it plain that he expects just as much effort this year.

Woe betide the trust or health authority chair or chief executive forced to preside over press reports of their organisation unilaterally closing its casualty department, or putting patients up on trolleys, or ferrying emergency cases hither and yon. Ministers are once again passing down the line what NHS chief executive Sir Alan Langlands and social services chief inspector Sir Herbert Laming last year described as 'non-negotiable' messages about winter emergencies. Just in case any have failed to grasp the imperative, Mr Dobson concludes his letter with the promise, 'I shall, of course, continue to take a close personal interest in the plans and arrangements being put in place'.

The NHS's performance last winter ranks among its successes: it coped. But several important factors in that success no longer apply or cannot be relied on this winter. Last winter was exceptionally mild and did not lead to any sustained outbreak of flu, which always swells numbers turning up at A&E as well as taking its toll among NHS staff. Remember December 1996 with its 10-day cold spell and cases of flu running at 200 per 100,000 population, compared to 50 last year.

Last year the service had an extra 300m specifically for 'winter pressures', though the pressures were comparatively gentle. While Mr Dobson described it at the time as 'not just an elastoplast for the winter', it was exactly that. He now cites the extra 21bn the NHS will soon enjoy as providing 'a firm resource base on which to plan'. But that is not the same as cash up front, and it won't be available until after winter.

Stakhanovite efforts are being directed to addressing Mr Dobson's other pressing priority - cutting waiting lists. They reached record levels partly because the service deferred treating elective cases in order to deal with winter emergencies. That option will not be available this year, and managers will have to reconcile two powerful and conflicting forces. They will have to do it while also devoting considerable time and effort to nurturing primary care groups and health action zones, not to mention curing the year 2000 bug. Twelve months on from last winter, the service's worsening staff recruitment and retention problems make everything that little bit harder.

It all adds up to a daunting prospect as the mercury begins to fall. And yet more discomfiting facts have emerged with the report from the Emergency Services Action Team on how the NHS managed last winter. Even in those mild conditions many hospitals still experienced 95 per cent bed occupancy. What is more, they will start the winter of 1998 already stretched by accelerating elective activity with which they are 'only just managing' to cope. The picture does not inspire confidence. Bad winter weather could plunge NHS hospitals into chaos. In the few short weeks of breathing space remaining, what should Mr Dobson do to minimise the risk of the service catastrophically failing its patients and most likely ending his political career?

First, he should listen to managers about what can be realistically achieved amid the plethora of priorities heaped on them since Labour came to power. Perhaps this would be an opportune moment to acknowledge that pursuing the holy grail of shortening waiting lists is not the best use of management time and resources. Second, he should not be shame-faced about bringing forward some of that 21bn for use this winter if it is needed.