The escalating risk shown last winter
Earlier this year the NHS experienced what many consider to be one of the toughest winters on record. Twelve-hour trolley waits in A&E departments and ambulance diverts increased. Performance against the 95% four-hour A&E wait target deteriorated. Many parts of the NHS operated for a number of weeks with unsafe levels of bed occupancy.
Critically, this translated into increased risk for patients as the whole health and care system struggled to cope under sustained pressure. A few local systems were unable to cope with this pressure for short periods of time as demand overwhelmed the available capacity. The NHS as a whole coped, but only just. This was mainly due to the extraordinary but unsustainable levels of discretionary effort from staff who reported themselves as having to shoulder an increasingly unacceptable burden.
Underlying this increasing risk is a simple truth. Current NHS capacity, which is largely static, cannot keep up with the continued growth in demand for services from a population whose profile is ageing and where the growth in patients with multiple co-morbidities creates greater patient acuity.
The NHS experienced record demand last winter. It also treated a record number of patients. But, in too many places demand overwhelmed capacity. Although the media focus was on hospitals, there was insufficient capacity right the way across local systems – in acute hospital, mental health, community and ambulance trusts, but also in primary and social care. A particular problem last winter was the rapid growth in delayed transfers of care (DTOCs) due to inadequate capacity in social care.
The NHS experienced record demand last winter. It also treated a record number of patients. But, in too many places demand overwhelmed capacity.
As soon as last winter finished, there were immediate demands for the NHS to learn lessons and to manage this growing risk more effectively. Although there are early signs from a small number of new care model vanguards that the growth in emergency demand can be flattened, there is every prospect that, over the next 12 months, demand will continue to rise. Growing workforce shortages and lower levels of funding increases threaten the NHS’s ability to match the capacity it provided last year. Some local systems are already reporting that the need for increased savings in 2017/18 is threatening much needed out of hospital and community capacity.
Planning for next winter
The government’s response has been to use the £1bn of extra 2017/18 social care funding announced in the March 2017 budget to try to reduce NHS social care related DTOCs and thereby free up 2,000-3,000 extra NHS beds.
Local authority budgets, which include provision for social care, have been cut by £18bn in real terms since 2010. They understandably argue that they are the best arbiters of how this extra investment should be spent. Faced with the need to ensure the investment was spent in time, the government agreed that the extra 2017/18 social care investment could be spent in three ways:
- to support adult social care
- to support the NHS through DTOCs
- to stabilise the social care market.
From the NHS perspective, this carries a risk of trying to spend the same £1bn twice, to get both a social care and an NHS benefit, and that the additional required NHS capacity cannot therefore be guaranteed. Now that local authorities are finalising how their extra social care funding will be spent, we can start to see how well and consistently government plans will work.
Our survey
We surveyed trusts in late May. This gave us a snapshot of how the conversations locally were developing and the results show a mixed picture:
- Only 34% of trusts report that their local authorities are giving high priority to supporting the NHS reduce DTOCs as opposed to meeting other/wider adult social care needs or stabilising their social care market.
- While 28% of all trusts have received a specific commitment that the extra social care money will be used to reduce delayed NHS transfers of care, 59% of trusts have not been able to secure such a commitment.
- Only 18% of NHS trusts are confident that the commitments they have received will help them meet the NHS England Mandate requirement to reduce DTOC levels to 3.5%, creating the required extra 2,000-3,000 beds.
- More positively 38% of acute providers feel that the extra social care funding will have a very positive or fairly positive impact.
We have translated this as meaning that the extra social care funding should help create the required extra NHS capacity in about a third of local systems but that, currently, it will not create the required capacity in the remainder.
Unsurprisingly, this will create a significant level of risk for the coming winter. Just 57% of trusts are confident they will be able to deliver safe, high-quality care this winter, while 10% are not confident – a much higher level than those overwhelmed by demand last winter.
Unsurprisingly, this will create a significant level of risk for the coming winter. Just 57% of trusts are confident they will be able to deliver safe, high-quality care this winter, while 10% are not confident – a much higher level than those overwhelmed by demand last winter. A worrying 33% are neither confident or not confident of their ability to provide safe, high-quality care. This suggests a significant level of risk, particularly if the NHS experiences the long periods of bad weather or widespread outbreaks of winter flu or norovirus it has avoided for the last three years.
The key factor underlying this risk is the lack of capacity to meet expected demand across local systems. In responding to the question “what level of capacity (physical and workforce) do you expect to have this winter?”, we had the following responses:
- ambulance – 64% of respondents reported a significant or slight lack of capacity
- acute – 71% reported a significant or slight lack of capacity
- community – 76% reported a significant or slight lack of capacity
- mental health – 80% reported a significant or slight lack of capacity
- social care – 91% reported a significant or slight lack of capacity
- primary care – 92% reported a significant or slight lack of capacity.
What action is needed?
If the government plan to create extra NHS capacity this coming winter through the £1bn of social care funding will help in around one third of local systems but not in two thirds of systems, there needs to be a different plan to manage the risk that trusts are clearly reporting. We held a member roundtable covering all four sectors of our membership – acute hospital, mental health, community and ambulance trusts – to identify what would most help the NHS frontline manage next winter, as well as using detailed responses to our survey.
The roundtable agreed that action needs to be taken on three time scales: immediate, short term and longer term. If the NHS does not embrace the longer-term perspective, our approach to managing winter pressures will remain ad-hoc and expensive.
Immediate measures
An immediate next step is to continue to monitor how the extra social care investment is being spent and ensure as much as possible is spent on DTOCs. The Department of Health argues that its plans, supported by a new Care Quality Commission inspection exercise covering 20 systems, will work longer term. The issue for the NHS is a simple one – can trusts be sure that by the end of July/August 2017, the required extra capacity to manage this winter will be created?
Short-term measures
Given that the current government plan looks like it will not create the required extra capacity, we clearly need an alternative means of creating it. Our proposals include:
- Funding and capacity
- an additional £350m investment in the NHS to give targeted support to acute hospital, mental health, community and ambulance services, distributed to those areas of greatest need
- committed by the end of July/August 2017 at the latest
- given the current £500-600 million system level gap for the NHS in 2017/18, and the need to commit this money within the next two months, we suggest the funding should either be a repayable advance or come from an early draw down on the extra £8bn committed in the Conservative manifesto
- Workforce
- increasing capacity by balancing the current approach on agency spending so that trusts have access to vital additional staff
- flexible approaches to staffing, for example boosting the nursing workforce, using a wider group of staff for some traditional nursing roles
- Resilience planning
- operational resilience planning across health and social care, with early checks from the national bodies to make sure plans are deliverable
- simplifying SITREP reporting to minimise diverting resource from the frontline
- a shift from assurance to support by national bodies to save time and help develop solutions.
Long-term measures
At the same time we need to create a long-term sustainable solution to urgent and emergency care that avoids the annual cycle of winter crises. We need to see:
- an appropriately funded urgent and emergency care system, including social care, and investment in an infrastructure that needs to grow to reflect growing demand
- a comprehensive workforce strategy that takes account of what the NHS is being asked to deliver and an approach to immigration which facilitates recruitment to key shortages in health and social care
- consistent membership and remit of A&E boards, planning which focuses on prevention rather than crisis management and seven-day service provision across a whole local footprint.
One of the key findings in our survey was the latest date by which any decisions on extra capacity had to be taken to enable trusts to recruit and staff that extra capacity. The results clearly show that any such decisions should be taken by end July 2017.
It is clear that the whole system needs to work together. Against this backdrop the NHS has a month to make concrete decisions on whether the current approach will work or, as our survey shows, more is needed to manage these risks.