A dance to the music of winter

Record low performance figures recorded last Thursday, challenging orders sent out from on high, and the first news this week of trusts planning to “suspend” elective operations for months on end — it’s beginning to look a lot like winter, writes James Illman.

As is becoming part of the winter ritual, staff are braced for a torrid few months, as system leaders with few levers left to pull pray the weather, flu and norovirus levels won’t be too catastrophic.

The service has, over the last couple of weeks, gone through its traditional start-of-winter dance, which involves a few simple steps.

Plunging performance. Check. System leaders sending out the obligatory letter with sensible sounding, but nigh impossible to deliver, objectives to trusts. Check. A few quid found down the back of the sofa chucked at a few arbitrarily selected trusts as the panic levels rise. Check.

An alarming new trend is the system seems to go into each winter weaker than the previous winter.

This year it comes off the back of the worst spring and summer performance on recent record, and the entirely avoidable pensions crisis has further exacerbated the staffing shortages blighting every part of the system.

It remains to be seen what impact the “stopgap solution” for pensions (sort of) announced by ministers this week will have. It will certainly not repair all the damage, which may actually be irreparable — our editorial here sets out why.

Another step in the traditional winter dance is the mass cancellation of elective work.

The orthodox model was for trusts to suspend some elective activity over the busiest part of winter, late December and January, to focus on emergency admissions. And then catch up over the summer when emergency demand fell.  

The model, however, no longer works because emergency demand is so high all year round that the spare capacity over summer never materialises. The waiting list has now ballooned to a record 4.42 million people, despite numerous central efforts to rein it back.

And, this year, Northampton General Hospital Trust has the dubious honour of being the first trust to, publicly at least, reveal a programme of mass elective suspensions, as first reported by HSJ this week. 

The trust said “some” non-urgent inpatient surgery was being suspended immediately until the end of March, as it tries to prop up its accident and emergency department. It apologised to patients and said the decision had been taken reluctantly.

The trust faced criticism from the Royal College of Surgeons, which raised “concerns” over what it said was a “drastic step” by the trust.

No doubt Northampton won’t be alone in taking such a move. In fact, I’d wager elective cancellations could also hit a record high this winter bearing in mind the system’s performance against the four-hour and 18-week targets. Feel free to file this away and call me out if I’m wrong come summer.

Good news

There has been positive news this week on flu.

A delay in the delivery of some batches of the nasal-spray flu vaccine to schools and GP practices sparked concerns last month that around a million children could be put at risk.

For the first time, every child aged between two and 11 is eligible for a free nasal spray inoculation. 

But leading clinicians told HSJ this week the vaccines were now arriving at the front line and it was “still early enough in the flu season for them to have maximum impact if administered soon”.

A more reassuring line came from the Royal College of GPs, which had initially raised concerns when the delays emerged.

Chair Helen Stokes-Lampard stressed, however, the “important thing is to make sure as many children as possible get vaccinated, so we would urge parents to arrange this for their child as soon as possible”.

Preparing the UK for flu, as the Royal College of Nursing’s professional lead for public health nursing Helen Donovan explains, is a hugely complex process with a lead time of around six months from when the World Health Organisation decides which virus needs to go into the vaccine.

This year, there was a short delay in the WHO’s decision-making process. There was then another delay during manufacturer AstraZeneca’s testing process.

But Ms Donovan neither put the blame on Public Health England, which procured the vaccine, or the drugs company. “I don’t think there is much either the manufacturers or [NHS] policy makers could have done differently. It’s a complicated process with a six-month lead in time, and sometimes these things happen,” she said.

She added the pause to the schools programme had been a “challenge” but agreed with Dr Stokes-Lampard’s assessment that there was still time to get children and those in the various risk groups vaccinated in time for the flu season, which usually starts to bite in late December or early January.

A successful schools vaccination programme does not, of course, guarantee flu will not paralyse the NHS this winter as it has done a couple of times in recent years, but the system appears far better placed than it did just a few months ago. 

PHE confirmed the pause had been lifted. It said in a statement: “We have now received further vaccine from AstraZeneca, and the temporary pause in ordering vaccine for the schools programme has been lifted.

“The primary schools-based flu vaccination programme is once again underway. Children that have underlying medical conditions who have had clinics cancelled at school should still go to [a] GP to get their vaccine.”