Patient impact
It is likely that patient experience and patient safety will be at risk if NHS trusts are unable to deliver the 2017/18 requirements. There is also likely to be an adverse impact on NHS staff. It is impossible to predict the exact nature and extent of these impacts but they include patients waiting longer for surgery and urgent care as set out below:
Patients waiting longer for elective surgery
Not meeting the 18-week elective surgery standard means that more patients will have to wait for elective surgery. In the previous section we identified that performance against the 18-week elective surgery standard in 2017/18 is unlikely to improve and is more likely to deteriorate.
NHS Providers estimates that, on the current trajectory, the average monthly waiting list in 2017/18 will be 4 million. To hit the 92% standard 3.7 million patients would need to be waiting less than 18 weeks. Forecasting from current performance suggests this figure will only be 3.6 million, meaning almost 100,000 patients will be waiting longer than they should.
The patient experience and safety impacts of these delays is well known and is set out in recent commentary from the Royal College of Surgeons and the Patients Association. These include:
- patients have to live with the consequences of debilitating conditions longer
- the risk of the condition worsening, requiring more complex, difficult and expensive treatment
- in the most extreme examples, conditions becoming permanent and untreatable.
Urgent and emergency care
Not meeting the 95% four-hour A&E target means that patient experience and safety in the provision of urgent and emergency care will also be adversely affected. In section 4 we identified that performance against the 95% four-hour A&E standard is unlikely to improve, will at best be maintained at current levels, but is more likely to deteriorate.
NHS Providers estimates that, on the current trajectory, 1.8 million patients will not be seen within the standard. The patient experience and safety impacts of these delays is, again, well known, and is set out in recent commentary from the Royal College of Emergency Medicine, the Royal College of Physicians and the Patients Association. These include:
- Patients having to wait for long periods of time in overcrowded and uncomfortable A&E department waiting rooms
- Patients’ conditions worsening significantly before treatment can be given, increasing patient safety risk.
The 95% target is widely regarded as a good proxy for the provision of high-quality urgent and emergency care. If performance drops below the 95% standard, patient experience starts to drop and risk increases. However, performance against the 95% target is not a particularly sensitive indicator of the most serious patient safety risk. For example, the Royal College of Emergency Medicine argues that performance below 75% is the point at which patient safety risk becomes seriously elevated on a systematic basis. Other measures of patient safety risk include persistent periods of 12-hour trolley waits, significant ambulance handover delays and bed occupancy rates over 85%. Throughout the three peak winter months general and acute bed occupancy did not drop below 89%, peaking at 96% in early February. This is in spite of additional capacity created by opening temporary (escalation) beds.
Experience over the current winter shows that performance against all these measures is deteriorating significantly at both an aggregate, system, level and, in particular, in a number of increasingly fragile local systems. As we pointed out in our November The state of the NHS provider sector report, there are now a number of local systems where the system is overwhelmed as demand rises well above the capacity level for sustained periods. NHS Providers has undertaken two initial analyses of performance over the 2017 winter period that highlight the significantly increased patient safety risk that some systems are now routinely running. We have also highlighted the risks of consistently high bed occupancy levels, in a joint letter with the Royal College of Surgeons. Our December 2016 survey also pointed to the fact that, in many systems, intermediate out of hospital bed capacity is declining. One estimate shows that, overall, as much as 8% of capacity has been lost over the last six years.
There are now a number of local systems that are being overwhelmed as demand rises well above the capacity level for sustained periods
There is widespread agreement from, among others, the Royal College of Emergency Medicine, the Society of Acute Medicine and the Royal College of Physicians that levels of NHS performance over the winter period were unacceptably low, risked patient safety, and need to be improved. This has been echoed by the secretary of state for health.
As set out in section 4, while improvement initiatives can ameliorate some of the impact of rapidly increasing demand for emergency care, they will not address the fundamental mismatch between current demand and capacity. The only way to deal with this is to increase capacity within the NHS, either through more inpatient mental health beds in the right locations, more community beds, more home care capacity or more acute hospital beds. It is impossible to calculate the exact investment required to deliver the right capacity increase however our estimate is £400-£600 million of A&E underfunding in 2017/18. Any investment should be targeted at the systems that need it most and where performance is in most danger of dropping to unsafe levels over a prolonged period.
Other targets
This analysis has focused on performance against the 18-week elective surgery target and the 4-hour A&E standard. Failure to deliver against other standards also means significant patient safety risk. Most obviously, the continuing inability of the provider sector, despite best efforts, to meet the cancer standard of 85% of patients having a first treatment within 62 days of an urgent GP referral, carries high patient safety risk. The latest data shows performance in January 2017 was 79.7%; the last time the target was met was December 2015.
Taking all this together, NHS Providers shares the recent judgement of the chief inspector of hospitals that “the scale of the challenge that hospitals are now facing is unprecedented - rising demand coupled with economic pressures are creating difficult-to-manage situations that are putting patient care at risk”. This applies to the entire provider sector, not just hospitals.
Staff impact
Trying to meet performance targets on inadequate funding levels is also placing an increasingly unsustainable burden on NHS staff. Although the 2016 NHS staff survey showed an overall increase in staff engagement it also showed that only 30% of staff agreed that “there are enough staff at this organisation for me to do my job properly”, with 47% disagreeing. 59% of staff reported working unpaid overtime each week.
Recent frontline testimony from this winter - “nowhere to go, not enough beds, corridor wards, patients in danger, stuck at hospital or sent home with support, pressure across the system, staff at risk of burnout” – also shows the increasing burden we are placing on NHS staff.