The ‘new’ NHS and the emergency care challenge

This is a critical time for the NHS, with many key themes to discuss. But my start to the year is dominated by emergency care – a very practical challenge but one that raises important questions about culture too.

Across the NHS we are really struggling with emergency activity. Even allowing for norovirus and prolonged cold weather we are experiencing unusual pressure.

‘Most believe NHS culture needs to change, but I am sensing uncertainty about whether it will or not’

The four-hour target and ambulance turnaround times indicate this pressure very clearly, and no one in acute hospitals wishes to see patients waiting for care or treatment, but what are the causes?

Acute hospital performance is, of course, crucial but the extent of the current problem means it is unlikely to be the sole reason that targets are being missed. After all, for some years now we have all taken similar improvement advice.

A key factor is an increasing length of stay caused by difficulty discharging patients from hospital who need continuing care, suggesting that investment in community and social care capacity is necessary.

Another might be the “demographic time bomb” – something we have expected for many years. Has it now gone off, as the Royal College of Physicians predicted it would, creating an acuity and dependency load that is too much for our existing service models?

A (lesser) factor might be the public preference for attending A&E, particularly when primary care out of hours services are known to be struggling.

Of course, a system running at over 90 per cent bed occupancy will topple frequently. Often we treat this as an acute trust performance issue, but this diverts focus from relevant system factors. And emergency care is central to the quality of care concerns highlighted by the Francis report – get this right and safety, outcomes and patient experience will all improve.

Collaborative leadership required

This is a wicked problem, which must be solved by a collaborative leadership approach bound by common purpose. Only then will the transformation necessary to create a joined-up, calmer and more controlled emergency care system be achieved, and the frequent crises eliminated.

This approach is difficult, because the present financial and performance levers work against collaboration, as does the prevailing organisation-based culture.

“The way we do things around here” is a definition of culture coined by McKinsey that works for me. Most believe NHS culture needs to change, but I am sensing uncertainty about whether it will or not.

‘There seems to be a consensus that our leadership style needs to change, but will our culture alter too?’

GP-led commissioning is already bringing a very welcome “clinical” focus, which may shift the culture in time. They seem keener on collaboration than their predecessors too, but will the new set of market rules hinder this? Like many I simply do not know at this stage.

We know too that we should facilitate greater patient and public involvement, and listen more, but there is no indication that central prioritisation will reduce in favour of greater local determination. Our communities will be rightly sceptical if we engage but then cannot act.

Finally, there seems to be a consensus that our leadership style needs to change, but will our culture alter too so that our new generation of non-pacesetting, collaborative and engaging leaders are able to succeed? If so, and I haven’t seen it yet, we may find emergency care and other wicked issues start to look soluble.

So, a landmark year but an uncertain one. The structural change may settle over time but many big questions remain unanswered as April gets under way.

Let’s see how we tackle the emergency care challenge − it will show whether the “new” NHS is different from the old one, or not.

Mark Newbold is chief executive of Heart of England Foundation Trust. This article also appears on the Nuffield Trust blog.