As soon as the pressures of last winter receded, there was a widespread call, spearheaded by NHS Providers, to start the process of managing risk for next winter and beyond, looking at both what needs to change now and tackling the underlying strategic issues (for example, NHS Providers calls for urgent review as winter pressures remain severe).
The government’s response has been twofold: additional investment in social care and prioritisation of A&E performance.
Additional investment in social care
The March 2017 budget included an additional £2bn for adult social care, of which £1bn was given to local authorities in 2017/18 through the Improved Better Care Fund (GOV.UK). The conditions attached to the funding meant that councils were given discretion on which of three areas to spend it:
- adult social care
- reducing delayed transfers of care (DTOCs)
- stabilising the social care provider market.
At the time the NHS was concerned that these conditions would not be strong enough to ensure that sufficient funds would be spent on reducing DTOCs. However, given the proximity to the start of the 2017/18 financial year, the government’s decision was not to be overly detailed or directive as the money would not be spent in time.
Both NHS Improvement and NHS England expected this additional investment to prioritise alleviating pressure on the NHS, by funding additional social care packages and in turn reducing the number of DTOCs. This was designed to free up 2,000-3,000 extra NHS beds.
Local systems were asked to reduce delayed transfers of care from health to social care to 3.5% (Mandate 2017/18, GOV.UK) and NHS Improvement wrote to all providers actively encouraging them to engage with their local authority(s) to discuss how this funding would be invested locally. However, it is worth noting that the NHS has not been able to meet a 3.5% DTOC level since quarter 1 of 2014/15 (figure 1 below), making it highly unlikely that the NHS will be able to meet this requirement by September 2017.
Figure 1
Prioritisation of A&E performance
The Next steps on the NHS Five year forward view document asked local systems to prioritise A&E performance, rather than non-emergency elective care, by linking the performance element of sustainability and transformation funding to meeting the four-hour A&E target.
As set out in the key deliverables for this year, by September 2017, over 90% of patients need to be treated, admitted or transferred in four hours. By March 2018, the majority of trusts are expected to meet the 95% standard, with full recovery by the end of 2018.
The national arm’s-length bodies also asked that each local (A&E or urgent and emergency care) delivery board consider implementing a number of initiatives in advance of the coming winter to improve patient flow:
- implement a comprehensive front-door streaming model
- hospitals, primary and community care and local councils working together to avoid DTOCs
- specialist mental health care in A&Es
- strengthen support to care homes (e.g. through direct access to clinical advice and onsite assessment)
- implement the recommendations of the ambulance response programme
- standardise walk-in centres, minor injury units and urgent care centres
- roll out evening and weekend GP appointments
- increase the number of 111 calls receiving clinical assessment.
For the provider sector the key question is whether these plans would go far enough to manage the risks particularly given that investment in reducing DTOCs could not be guaranteed over the other priorities identified for the additional social care funding.