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The NHS is heading into a challenging winter with many of its traditional demand control levers unavailable or under-powered, James Illman argues.

NHS Improvement’s first quarterly report of 2017-18 published this week sparked fresh warnings that the health service is in worse position heading into winter this year than 12 months ago.

And running through the potential levers system leaders have left to pull to intervene when demand cranks up over the coming months, it is clear why there are such widespread fears this winter could be worse than last year.

Last winter saw the following significant central interventions:

1. Extra NHS funding: the £335m winter pressures fund was allocated in December, far too late to be spent optimally with most of it used to bolster trusts’ bottom lines. But it did finance much-needed extra capacity both in the NHS and the independent sector, without which performance could have been even worse.

2. Extra social care funding: £1bn was allocated to councils for 2017-18 to help support a national drive on cutting delayed discharges. The money, part of a £2bn package for local government unveiled in the 2017 Budget, prompted feisty discussions between local government and NHS about how best to spend it. But ensuring delayed discharges of care begun to decrease was viewed by many NHS leaders as the main success of last winter.

3. An elective moratorium: system leaders ordered an elective freeze in the festive period, as it had done in 2016. It then extended it over January and predicted around 50,000 operations could be postponed. Many trusts however opted to ignore the opportunity and the move actually resulted in only 22,800 postponed operations.

4. Relaxing rules on mixed sex wards and other measures: NHS leaders also ordered commissioners to suspend mixed sex breach fines.

5. Vaccinations drive: Around 69 per cent of frontline workers received a flu jab last year, the highest ever. But the drive came with efficacy concerns, while senior leaders called for debate about mandatory jabs.

This winter however, some of these interventions are either not on the table at all or significantly diminished.

1. There is no extra NHS funding: No fresh winter pressures funding has been allocated so far this year. However £145m of capital funding was brought forward to help upgrade wards and EDs, as well as open 900 extra beds. This was welcomed by the recipients. But the system is at least 4,000 beds short - on the most conservative estimate - and there is a feeling ministers could have done more.

2. There is less social care support: The £2bn DTOCs funding was frontloaded. It tapered down from £1bn last winter, to £674m this year and then £337m in 2019-20. NHS Providers tell me trusts were already feeling the pinch because of this. Losing last winter’s hard fought gains on DTOCs would be a major blow. Indeed, many NHS leaders still believe the best way to bolster the health service this winter lies in more money for social care.

3. An elective moratorium: such a move could still be rolled out but it has polarised debate. Senior surgeons raised concerns that the waiting list is already spiraling out of control while acute medics argue without such a move, the system will simply fall over (see below: Polarised views on an elective freeze).

4. Vaccination drive: NHS chiefs have told providers they expect “near universal uptake” of staff getting a flu vaccination this winter.

5. Increase use of the private sector: Independent providers estimate they could carry out around 100,000 additional inpatient procedures by the end of the 2018-19 year, in one piece of research. But NHS Providers warn this would destabalise the finances of already hard-up NHS providers.

Polarised views on an elective freeze

An eight-week elective moratorium from the festive period onwards is needed to help the system cope with winter demand, the Society of Acute Medicine told HSJ.

But senior surgeons remained cautious about the prospect after last winter’s freeze was not followed up by the anticipated elective catch up programme over summer.

SAM president Nick Scriven told HSJ: “We would propose an eight-week elective freeze starting from Christmas with the caveat that anything urgent like cancer operations, would go ahead as soon as possible

“It would have of course been preferable if such a move was announced earlier in the year so surgeons could adjust their lists and balance their outpatient work accordingly, but staff and patients instead will head into winter with uncertainty on this.”

He added: “There should also be a more mandatory approach taken by the centre. There is clearly a need for some local flexibility, but last winter was very patchy in terms of how many trusts actually followed the central advice.”

The Royal College of Surgeons has however already raised its dissatisfaction that last winter’s moratorium was not followed up by a catch up programme.

Both positions are understandable: while A&E performance plummeted to record lows last winter, the waiting list has since spiraled from 3.84m in March 2018 to 4.11m in June alone.

System leaders - already facing the Sisyphean task of balancing the elective waiting list and deteriorating four-hour target performance, as well as not pushing NHS trust finances further into the red - need all the help they can get this winter. But have instead been dealt a cruel hand, despite the promise of longer-term funding. Much now will depend on another impossible-to-control variable: the weather.