Press coverage of the recent “Next Steps on the NHS Five Year Forward View” concentrated heavily on the argument that a lower 18 week elective surgery target in 2017/18 will make it easier to recover performance against the four hour accident and emergency target.
Whilst the lower elective surgery target is a welcome, but painful, acceptance of reality, the linkage between the two targets is neither direct nor strong. And over emphasising that linkage underplays the serious risks the NHS faces next winter.
NHS performance between December 2016 and March 2017 showed the service is now running a higher risk in the provision of urgent care than at any point over the last decade.
The 95% four hour A&E target isn’t a particularly good measure of that risk – the Royal College of Emergency Medicine argues that 75% performance against the four hour standard is the “magic mark for safety…when it becomes very overcrowded and…unsafe”. Better measures of patient safety risk are the levels of hospital bed occupancy, ambulance hand over delays, and the number and frequency of long hospital trolley waits.
"Whilst the lower elective surgery target is a welcome, but painful, acceptance of reality, the linkage between the two targets is neither direct nor strong."Chief executive, NHS Providers
All of these took a significant turn for the worse last winter. A third of hospitals had bed occupancy rates of 100% on at least one day. Many reported trying to manage bed occupancy levels well over the recommended 85% - 90% level for weeks on end. This required continual, very difficult, “one in, one out” admission / discharge decisions that usually led to worse care for the patients concerned. Ambulance diversions - hospitals turning away ambulances because they were full - were up 85% compared to the previous year.
Whilst the NHS as a whole just about coped with record levels of demand, a number of local systems were overwhelmed for periods of time, putting patients at unacceptable risk.
Hospital and ambulance trust leaders are now concerned at their ability to manage this growing risk and that the number of systems in danger of falling over next winter is rising. Their colleagues in community and mental health report similar pressures, risks and concerns though, frustratingly, we either don’t have the public data to show this or the data is too new to be robust.
Aiming for a lower 18 week elective surgery target will, in many instances, make little difference, for three reasons.
"Aiming for a lower 18 week elective surgery target will in many instances make little difference"Chris Hopson - Chief executivetweet this
First, many hospitals are now undertaking such relatively low levels of elective activity that they are, in the words of a recent Health Foundation Report, “becoming more of an emergency service”. Relaxing elective surgery performance targets won’t help them much.
Second, most hospitals have already scaled back on their elective work over the crucial winter period. Indeed, they were formally instructed to do so by NHS Improvement. Relaxing the elective surgery target won’t create much extra winter capacity as it has already largely been freed up anyway.
Third, urgent and emergency care performance is not just about hospitals. Whilst concentrating more hospital capacity on emergency, as opposed to elective, care may help a little, it does nothing to address the problem of capacity constraints in primary and social care and the ambulance, community and mental health sectors.
"If we want to manage growing risk, we have to increase capacity to match growing demand."Chris Hopson - Chief executivetweet this
The NHS can no longer do everything. Trying to hit the elective surgery target would have required the service to abandon proposed increases in cancer, mental health and primary care funding. But relaxing the target does have unwelcome side effects. As the £300 million deterioration in last year’s trust finances at quarter 3 showed, reducing elective surgery seriously hits trust financial performance just when we are trying to recover it. Delaying surgery also risks turning some cases into emergencies, adding to the urgent care burden.
Good urgent care largely depends on supply and demand across a local geography. The NHS currently struggles with winter pressures because we simply don’t have enough capacity. If we want to manage growing risk, we have to increase capacity to match growing demand.
We need to increase capacity in primary care, where the number of GPs is actually falling, not rising. We need to increase capacity in out of hospital care, not reduce the number of out of hospital beds by 8% as happened between winter 2016 and winter 2017. We need to increase capacity in social care, not cut the number of care packages available, to reduce delayed transfers and enable hospitals to properly manage their patient flow. And we need to increase temporary capacity in both acute hospitals and ambulance services too, if that’s what’s needed. It’s important to note that we added eight extra hospitals' worth of temporary acute bed capacity last winter and still struggled.
What we shouldn’t do is kid ourselves that relaxing the 92% 18 week elective surgery target is any real substitute for that extra urgent and emergency care capacity. It isn’t.
This article first appeared in the Guardian Healthcare Network on 12 April 2017