Is the plan for next winter working? Evidence from the front line

NHS Providers surveyed the NHS frontline to find out whether the plan was working and how well it would manage risk. We surveyed all types of provider trusts – acute hospital, mental health, community and ambulance – to understand, test and explore:

• the level and nature of provider involvement in discussions about how additional social care funding is being invested locally
• levels of confidence that additional social care funding will support the NHS to manage winter pressures this year, including the reduction in delayed transfers of care (DTOCs)
• the areas in the system where capacity will be most constrained this winter
• what additional support is required for all types of trusts and local health economy partners to manage winter pressures.

We had responses from 93 trusts which is 40% of the NHS provider sector. The survey has given us a snapshot view of how discussions are developing and how trusts are responding to the challenges.

The following two sections set out the results of the survey data:

• the first looks at how the additional social care funding is being spent, the discussions around this and the impact funding decisions will have on DTOCs
• the second looks at trusts’ confidence in managing risk this coming winter.

Survey results on additional social care investment

The first part of our survey looked at how the extra £1bn social care money for 2017/18 is likely to be spent and how local discussions were progressing.

Variation in the level of trust engagement in local discussions

Substantial emphasis has been placed on the importance of local systems working together to agree how the extra 2017/18 £1bn investment in social care can be deployed to best effect. However, as the evidence shows, provider engagement in the discussions is very variable. Only 50% of trusts felt involved in discussions with their local authority(s) about how the funding is going to be spent (figure 2).

Furthermore gaining access to discussions appears to be more challenging for mental health, community and ambulance providers, with only around a third (31%) indicating they are involved in discussions.

The variability between and across providers and local authorities is particularly striking. Survey responses show one trust might have positive discussions with one local authority but have challenging discussions with the neighbouring local authority. At the same time, an acute provider might have constructive discussions with the same local authority that a mental health provider has found it challenging to engage with.

This variability might, in part, be a symptom of the delay in publishing the Improved Better Care Fund guidance for 2017/18. In the absence of clear guidance, the format and governance of discussions have been left to individual local health and social care economies to determine. It is, nevertheless, disappointing that three years in to the Better Care Fund, the key vehicle intended to bring health and social care together, there is still so much variability in the extent to which NHS organisations are brought in to these important discussions.

Settings and structures in which the discussions are taking place

Discussions about the additional funding and how it will be spent are taking place in different ways across the country with over a third (33%) indicating that local partners were having separate, dedicated conversations (figure 3). Just over a fifth of organisations (23%) indicated that discussions were taking place at A&E delivery boards. Although across many local health and social care economies, these boards cover urgent and emergency care more broadly, the recent focus on A&E performance both nationally and locally, has potentially limited the involvement of community and mental health providers.

How will the social care money be spent?

The guidance allows local councils to spend the extra £1 bn for this year in three different ways:

• meeting adult social care pressures
• reducing pressures on the NHS
• stabilising the social care provider market.

There are clear and well-documented pressures on social care, and the need to give councils some flexibility around how the money is spent is understood. For example, the fragility of the social care market is well recognised: at the moment, one care home is shutting every week (Guardian 2016).

Social care services are seeing increased demand, driven by the more complex needs arising from an ageing population; reduced funding; and increased costs due to the introduction of the national living wage. Like healthcare, the sector is also facing severe workforce shortages. For example, vacancy rates for social workers in the public sector rose from 7.3% in 2012 to 13.1% in 2015 (Health Foundation, 2016: Election briefing: A sustainable workforce – the lifeblood of the NHS and social care). It is therefore understandable that some of the investment for social care needs to be targeted to support the social care market.

However, the Department of Health and its arm’s-length bodies have also been clear that they expect to see a reduction in DTOCs from the NHS to social care as a result of this targeted investment. The proportion of the funding being dedicated to reducing the pressures on the NHS, as opposed to the adult social care or the care home market support, will be key to delivering NHS plans to manage next winter.

We asked trusts how spending was being allocated across the three priorities.

From our survey results, around half of trusts indicated that funding is being spent to meet adult social care needs as a top priority in their local area, with 30% supporting the local social care provider market as their top priority (figure 4). Worryingly, reducing pressures was only a high priority identified by a third of trusts (34%), a medium priority in 46% and, most concerningly, a low priority in 20%.

To gain further insights into how the social care funding would be used, we asked trusts if they had obtained a specific commitment for the funding to be spent in a way that reduced DTOCs, as the Department of Health plan intended.

Only around a quarter of trusts (28%) have had a specific commitment that the funding will help reduce DTOCs (figure 5), a percentage which increases slightly in the acute sector, with 38% reporting that they have received a specific commitment.

It is positive that 28% of all trusts and 38% of acute hospitals believe the money will flow as the Department of Health intended. However, it remains worrying that at the point the survey was completed, the remainder – around 60% - had not secured this commitment.

The key issue for the NHS is whether the extra funding will translate into reducing DTOCs to the extent required. We asked trusts whether the way in which the funding was allocated would support them to meet the NHS mandate target of reducing DTOCs to 3.5%.

Again the survey results were worrying. Just under 20% of NHS trusts in our survey are confident that the additional social care investment going to local authorities will support them to reduce DTOCs. It is concerning that 42% were not very or not at all confident.

Finally, on social care funding, we asked more broadly about how the additional money is being invested will impact on trusts’ ability to manage winter pressures (figure 7).

A number of reasons emerge for this lack of confidence in the efficacy of additional social care funding:

• After seven years of cuts in social care funding, alongside increasing demographic and cost pressures, the Local Government Association predicts a £2.6bn gap for social care by the end of the decade (Guardian 2017). This means that the funding might, at best, only be able to hold services at their current level rather than lead to additional capacity in social care.
• Often schemes are funded on an ad-hoc and non-recurrent basis, but trust leaders are concerned that unless viewed as part of a wider joined-up system strategy for tackling DTOCs, they are unlikely to make a difference in isolation.
• Confidence in the funding is much lower among community and mental health trusts. Only 7% have been given a specific commitment to reduce DTOCs, which suggests that the focus is disproportionately on the hospital sector, at the expense of looking at the drivers of DTOCs across the system. This is at odds with what providers tell us they need: additional capacity in community, mental health and out of hospital settings.
• Discussions locally have tended to focus on inputs, rather than identifying the necessary outputs and outcomes required to reduce DTOCs.
• In previous years, discussions about planning additional capacity happened late and often without the necessary lead times to ensure best use of resources. As one trust explained “discussions about how the funding will be invested are so little and so late in the day, that I have no way of knowing at this stage if there will be a positive or negative impact…I assume the worst case until I hear differently.”

It is positive that the survey shows there are a number of trusts and local systems – around a third – where it is likely that the social care funding will directly help reduce DTOCs. And, some of the spending on other priorities will provide extra care packages to meet adult care need and this should, by definition, help the overall health and care position in a locality, even if it does not directly reduce DTOCs.

However, overall, the survey results show that the NHS is unlikely to experience the gain in capacity – estimated at the equivalent of between 2,000-3,000 extra beds – that it needs. If we are to manage the risks of next winter, we will need to find alternative ways of generating the required extra capacity.

Survey results on trusts’ ability to manage risk this coming winter

The second part of our survey looked at the wider issues of frontline trusts’ confidence in their ability to manage risk next winter.

We asked trusts about their confidence in their ability to deliver safe, high quality care this winter (figure 8). Although the majority of providers (57%) are confident, it is worrying that 10% are not confident, with 33% neither confident or not confident. This suggests that there will be significantly more trusts under pressure in the coming winter than there were last winter. 

It also shows that the current plan for tackling winter pressures this year, in the form of additional social care funding and a national focus on improving A&E performance, is unlikely to be sufficient.

Why are trusts not confident they can manage next winter’s risk?

Our survey shows that, as with last winter, it is insufficient capacity across all parts of the health and care system that underlies this risk.  It is striking that, when asked if their local system has the right capacity, trusts point to major capacity constraints across their whole system. As figure 9 shows:

• ambulance – 64% of trusts report a significant or slight lack of capacity
• acute – 71% report a significant or slight lack of capacity
• community – 76% report a significant or slight lack of capacity
• mental health – 80% report a significant or slight lack of capacity
• docial care – 91% report a significant or slight lack of capacity
• primary care – 92% report a significant or slight lack of capacity.

Clearly the highest levels of capacity concern focus on social care and primary care, reflecting the extent to which providers are heavily dependent on other parts of the health and care system. When capacity is constrained in these areas then the whole system faces real problems. A good example of the impact of this is in primary care.

How much difference will the March A&E recovery plans and the Next steps on the NHS Five year forward view document help to manage risk next winter?

Just under half (45%) of trusts were confident that the urgent and emergency care deliverables set out in the Next steps for the NHS Five Year Forward View would have a positive difference to managing winter pressures locally (figure 10).

Again, there are a number of reasons why trusts are concerned that many of these measures are unlikely to make a positive difference this winter, mainly focusing on wider system constraints such as capacity, funding and workforce. For example:

• One mental health trust commented that it is “all very well having mental health support in A&Es, however if the mental health inpatient units are full, we still will not be able to respond to the increase in demand.” This illustrates the importance of putting in place a system wide capacity plan, as additional resources in one part of the system might put pressure on another part of the system.
• There are substantial workforce constraints, limiting the ability of trusts to implement some of the initiatives, such as:
  • the challenges of rolling out GP streaming at A&E when there are already shortages in core primary care services
  • the need to implement additional ambulatory and frailty support when there are significant shortfalls in nurse recruitment
  • widespread recruitment challenges in the home care market.
• These changes will take time to bed in. Although national guidance is helpful, trusts still need the flexibility to design schemes and pathways which best meet the needs of their patients locally. One trust chief operating officer commented that “I don’t think we need more policy, just time to implement what we have, alongside room for local interpretation… we already have an innovative form of streaming to primary care and urgent care services… we want to go further to build a wider clinical hub adjacent to the emergency department, changing the model of care to reduce the likelihood of admission to hospital”.
• The recently allocated £100m capital funding for A&E is welcome, but many parts of the country might be unlikely to use it quickly enough to make a tangible difference this winter.
• Revenue support is required for many of the initiatives proposed in the key deliverables. For example, to fund GP streaming could cost around £0.5-1m per centre on a recurrent basis. Many trusts currently do not have this kind of surplus to support this initiative, and it will require funding from commissioners.

The emerging picture for this winter

The traditional pattern for winter planning has been creating capacity to cope with peak demand in the winter months followed by relative respite during summer. However, this approach no longer applies and the system has needed to focus on year-round operational resilience which is resource intensive.

Trusts will still work hard to ensure that they are creating as much free capacity as possible in preparation for the winter months. This in part relies on being able to recover performances after winter which may prove challenging this year.

In summary, our survey shows that the current plan of freeing up 2,000-3,000 NHS beds through the extra £1bn of social care funding is only likely to work in around a third of trusts. With 43% of trusts not confident they can manage next winter’s risk safely, more is needed.