What more do NHS providers need to manage risk safely this winter and beyond?

Many of the risks facing the health service this winter are symptomatic of the wider challenges facing the NHS. So there are no silver bullets. However, structured conversations with provider trust leaders at a roundtable discussion in May 2017 and detailed responses to our survey questions have helped to identify a number of immediate and longer-term proposals to help manage this winter’s risk. These proposals will support the NHS as it goes in to this winter and will also help to start the process of putting the whole urgent and emergency care system on a more sustainable footing for the future. 

These proposals are set out below, offering immediate and longer term measures for the following three areas:

• funding and capacity
• workforce
• resilience planning and assurance.

Funding and capacity

Immediate measures

The NHS requires additional capacity urgently. Providers say this can only be delivered through an emergency cash injection in the form of winter resilience funding.

Trust leaders were asked what level of additional funding they would need to be confident of delivering safe, high-quality care this winter. NHS Providers analysis of this data shows that around £350m is required for the NHS provider sector to help manage next winter’s risk.

We asked trusts the latest date by which they need to know that additional funding or capacity would be received to make a positive difference during the coming winter (figure 11).

Over half of trusts said that they needed to know during July or August at the latest. Given the planning time required to commission and staff new capacity, decisions on additional investment need, ideally, to be made by the end of July or August in this timescale. The current workforce constraints mean trusts need as long as possible to find the necessary staff. The later the decision is made, the more money is likely to be eaten up in agency staffing fees. 

How would the additional investment be used?

When considering how to use additional investment to create capacity, it is critical to avoid a narrow focus on acute hospital capacity. Urgent and emergency care is a cross-system issue, and depending on the particular composition and challenges facing different areas, the money could be spent on:

• Investing in bed capacity out of hospital. Many trusts say additional bed capacity in the community and mental health sector is urgently required for this winter. This could help tackle pressure on acute bed capacity, for example by providing step-up facilities to keep patients out of hospital, or by providing assessment beds required to support the discharge to assess pathway. Several acute trusts are also looking to roll out virtual wards in the community to care for patients outside the hospital, which additional funding could support. Additional escalation beds in the acute sector will also be required, and this needs to be considered as part of a wider strategy to ensure sufficient bed capacity across the whole system.
• Expanding ambulatory care. Additional funding could support the further expansion of ambulatory care, allowing trusts to remove patients from acute medical units and emergency departments in a timely way, before their condition further deteriorates.
• Recruiting medical, nursing and care home staff. Employing temporary staff when there are already widespread vacancies in the permanent workforce is challenging. However, the early release of winter resilience funding will give trusts an opportunity to undertake the necessary recruitment well in advance of winter, rather than having to resort to expensive agency staff.
• Investing in the ambulance sector. Ambulance trusts play a crucial role in managing demand and improving patient flow in the urgent and emergency care system. Additional funding could, for example, support the expansion of hospital ambulance liaison officers at each major acute hospital to ensure smooth and timely handover of patients and minimise delays in emergency departments. Additional clinical staff, including advanced trained paramedics, nurses and mental health nurses, could also be placed in clinical hubs to further reduce the number of patients conveyed to emergency departments. Additional capacity in discharge and transfer ambulances could support discharging patients by conveying patients to step down facilities.
• Creating additional packages of care and residential placements, including reablement. Trust leaders are not confident that the additional social care funding will lead to sufficient social care provision, and at best might only be able to hold existing provision for this winter. Additional funding would help support trusts to work with local authority partners to put in place more social care capacity, including packages aimed at keeping people out of hospital in the first place.
• Expanding mental health crisis care. There is a strong case for ensuring that additional investment is used to ensure comprehensive 24/7 mental health crisis care across the country to prevent hospital admissions. Funding could also be used to support new models of care such as mental health street triage so that people are assessed in the community before their condition deteriorates and requires an inpatient stay.
• Targeting support to primary care and social care. Too many admissions to hospital still come from primary care and social care, where there is often a lack of confidence and capacity to keep people out of hospital. Investing in trusts to provide targeted support, whether remotely or physically, to nursing homes, care homes and primary care, could help increase capacity in primary and social care.

This range of options demonstrates that there is no single right answer to how extra money should be used to create capacity. The key is to ensure that local systems are empowered to make the decisions that best suit their needs.

Principles for allocating funding

Allocating winter resilience funding in a fair and effective way is complex. The NHS has a long history with regard to winter funding and, up until 2014/15, additional funding was made available nationally, part way through the year, to sustain the urgent and emergency care system during winter. NHS Providers argued that this approach had two key disadvantages: it gave no planning certainty and the money often arrived too late during the year to spend with maximum effectiveness. We therefore argued that the money should be mainstreamed through the main NHS budget setting and planning process but with specific sums earmarked for winter resilience.

From 2015/16, the funding was incorporated in to CCG baselines, with the intention that this would enable systems to plan properly and early enough. However, very few trusts have continued to receive dedicated winter resilience funding, further exacerbating efforts to manage winter pressures.

In reality, dedicated winter funding has, in very many cases, been used for general funding. The proposed earmarking of funds has failed. Ultimately, significant amounts of extra capacity that were previously funded via winter pressures funding has no longer been commissioned at all (NHS Providers, 2016). This cannot be right.

In reality, dedicated winter funding has, in very many cases, been used for general funding. The proposed earmarking of funds has failed.

   

Allocating funding midway through the year is not ideal. However, it is now urgently required to support the health and social care system this winter, alongside a commitment to pursue longer-term solutions to ensure sustainability and performance across the year as well as over winter. 

A number of decisions would need to be made about the source of the additional investment. As a proportion of an annual budget of around £90bn for provider trusts, £350m is very small. However, given the extreme financial constraints the NHS faces – at June 2017, there is a £500-750m system level financial gap for 2017/18 – other approaches need to be considered. Given the speed with which the money is needed for 2017/18, it could be committed as a loan that would be paid back through other routes the following year. These routes could include recouping costs currently tied up in back office, administrative functions at a national level. Or the NHS could make an early draw down on the extra £8bn committed to the service in the Conservative manifesto.

Decisions also need to be made about:

• how to allocate winter resilience funding, including whether funding flows directly to providers, or through commissioners or another vehicle
• how to determine what level of funding providers receive, given that if purely allocated to emergency activity or performance alone, other parts of the urgent and emergency care system would lose out.

Key principles for the distribution of this funding need to include:

• Immediacy. Any additional funding needs to be put in to the system immediately, if the NHS is to use it to best effect. Leaving it too late could leave organisations with limited opportunities to invest the money effectively.
• Balancing simplicity with accountability. With any additional investment made in the NHS, it is important to demonstrate how it is being used to the benefit of patients. The need to provide assurance over how the additional funding is being spent needs to be balanced alongside the need to ensure that this funding is allocated in the simplest way possible, without substantial strings and conditions attached. This proposed additional investment is to plug an existing gap and mitigate existing risk. It is therefore a means of helping assure delivery of the performance levels that have been already set, not increasing them.
• Cross-sector. Traditionally, the acute sector has benefitted most from winter resilience funding, at the expense of the mental health, community and ambulance sectors. That said, investment with an acute provider does not necessarily lead to more capacity in the acute sector alone, as we are seeing an increasing number of acute providers buying capacity to support the mental health, community and social care sectors. Resilience funding needs to reach all parts of a local system, rather than being made available on a bidding basis, which can overlook those most in need.
• Recurrent and ring-fenced. To put the urgent and emergency care system on a more financially-sustainable footing, funding needs to be recurrent, and if it is incorporated into CCG baselines it also needs to be ring-fenced. Pressures on the NHS over winter will continue to grow in line with cost and demand growth. Therefore the response needs to be recurrent funding.
• Transparency. Any additional investment in the NHS this winter needs to be allocated in a transparent way, so that there is a clear link between investment made locally and additional capacity bought. The only way to clearly demonstrate this would be through directly allocating to providers.
• Tackling areas in most need. The maturity of local systems varies in terms of operational resilience planning. Suggestions to allocate the funding to sustainability and transformation partnerships or urgent and emergency care boards will only advantage those systems with mature relationships, and could mean that the very systems most in need would lose out. A simple approach is key to ensure that the NHS uses this funding in the most effective way possible.

Long-term funding measures

In the future providers need:

• An appropriately-funded urgent and emergency care system, including social care. The payment system (the national tariff) fails to appropriately reimburse the costs acute providers face over winter and, combined with the continuation of penalties for over performance, leads to providers losing millions of pounds which could otherwise have been reinvested back in to patient care. We need to fix the financial imbalance between elective and non-elective care, and between acute and non-acute providers. Separate funding arrangements for other parts of the urgent and emergency care system, including mental health, community and ambulance, mean that incentives are not aligned to support effective financial planning at winter.
• Investment in infrastructure. Most hospitals are now treating tens of thousands more in their A&E department than originally planned. Trying to manage ever-increasing acute demand in hospital without increasing physical infrastructure is not sustainable. Hospitals need capital to reconfigure their emergency departments and improve flow and layout. The additional £100m capital investment announced earlier this year is helpful, but it is only designed to enable front door GP streaming. It doesn’t help most providers undertake the broader transformation required. We need to recognise that continuing to restrict capital spending is preventing providers doing their best for patients.

Workforce

The recruitment and retention of staff is now one of the biggest challenges facing NHS leaders. In our first State of the NHS provider sector report, 59% of trust leaders considered that they don’t have the right staff numbers, quality and mix to deliver high-quality care.

Being able to respond to winter pressures is only possible with the outstanding effort, commitment and professionalism of frontline NHS staff. However, staff are now often being required to work way beyond the reasonable call of duty to ensure patients are given high-quality and safe care. NHS professionals are working under greater pressure and intensity. In last year’s staff survey, nearly two in five staff reported that they had been ill in the past 12 months due to work-related stress. This is true for nearly half (49%) of all ambulance staff (Health Foundation, 2017).

There are high vacancy rates in job groups critical to supporting the urgent and emergency care system, including A&E consultants, psychiatric nurses, home care workers and general practitioners.

We need to manage these pressures both for the coming winter and in the longer term. 

Immediate measures

• Balancing agency spend with the need to increase capacity this winter. With workforce shortages so widespread, trusts are often left with few alternatives other than to employ costly agency staff to increase capacity over the winter period. The agency cap has succeeded in pushing agency staff back in to permanent roles, however trusts still need to have the flexibility to access additional staff. The national arm’s-length bodies must take a proportionate approach to the use of agency staff in the NHS this winter recognising that, in the short term, there will be a legitimate need to use temporary staff to increase capacity. In recent months, there has also been a disproportionate increase in the reporting requirements around agency staff. These arrangements need to be simplified as soon as possible to ease the burden on the already stretched frontline.
• Bolstering the nursing workforce in the short term. Trusts do their best to avoid using agency staff unless it is absolutely required. There are no quick fixes to the high vacancy rates in the nursing workforce, but trusts are looking to bolster the nursing workforce in the short term by using different staff such as allied healthcare professionals, pharmacists and physiotherapists to undertake a range of roles traditionally filled by nursing staff. This approach will require backing and support from NHS system leaders.
• Flexibility over NHS staff. The Next steps in the NHS Five year forward view called for emergency performance to be prioritised over other areas such as non-emergency elective care. However, the NHS workforce is not currently set up in a way to enable this flexibility of approach – switching capacity between different priorities. We need to quickly identify what is needed to create the required flexibility, for example working with Health Education England and deaneries to support junior doctors to work more flexibly in trusts.

Long-term measures

• A comprehensive workforce strategy which takes account of what the NHS is being asked to deliver and which facilitates recruitment to key shortages in urgent and emergency care.
• Greater flexibility between NHS and social care workforce. NHS staff are employed on different terms and conditions to social care workers and we need to simplify these arrangements so that our workforce can be used more flexibly to fill gaps. This will be challenging. But many trusts now recognise that they can support the social care market themselves, either by directly employing social care workers or by designing new models of care delivery, such as looking to health care assistants to work in domiciliary care settings. One northern trust is even looking at how to leverage social care staff in an acute setting, when someone with a social care package is admitted in to hospital. At the moment, when a patient with complex needs is admitted, their social care package is often disbanded and workforce re-allocated. This means that work has to start afresh to secure a new social care package for a patient when they are ready to be discharged. In future, when that patient is admitted, social care workers could be directly involved in supporting that patient in hospital, so that there is continuity of care and the resources ready for when that person is able to be discharged.
• An immigration system which facilitates recruitment to key shortages in the health and care system. It is clear that for the foreseeable future high-quality and sustainable health and social care services will continue to depend on workers from outside the UK. Extending the current work visa system for people outside the EEA to include those inside would not support this, as the existing system is not fit for purpose and poses too many barriers to recruiting sufficient numbers of staff. Any new system needs to take account of the value and contribution the health and social care sector provides to the UK economy and population, with public service value used as a key assessment of ‘skill’ as opposed to salary. This will enable recognition of the range of roles we will need to recruit.

Resilience planning and assurance

Trusts have worked hard with NHS Improvement and NHS England to improve local system management, to empty beds in preparation for the period of greatest stretch and systematically improve performance. However, planning is still too variable across the country, and urgent and emergency care boards/A&E delivery boards are not yet working effectively across the country. To overcome this, providers need to see the following.

Immediate measures

• Early triangulation from the national bodies. An early check from arm’s-length bodies on the deliverability of winter plans is required to ensure that those areas struggling to reach agreement on additional capacity are identified and providing them with support to create it.
• Operational resilience planning across health and social care. Many trusts and local authorities are working more closely together on a week-to-week basis, which should be encouraged. For example, several local areas have set up weekly meetings with chief operating officers across the health and social care system to ensure that there is a good line of sight over whole pathways of care.
• Move from assurance to support. Substantial senior management time is lost during winter to daily conference calls with the arm’s-length bodies. As one chief operating officer told us, these calls “exist to provide assurance to the national level rather than develop solutions” to the challenges providers are facing on the ground. Another commented that the “culture of assurance has gone too far” with trusts spending a lot of time collating information for regulators, simply reporting the situation on the ground.
• Simplify SITREP reporting. There is currently a high level of burden associated with SITREP reporting, with many trusts having to employ dedicated staff just to comply with the reporting procedures. One trust told us that the day they had to trigger an OPEL 3, the people required to generate all the paperwork were the same ones required to deal with the problem on the ground. This is counterproductive, and the process needs to be streamlined.
• Greater alignment between national bodies. Trusts continue to report that the duplication in regulatory efforts between NHS Improvement and NHS England is significant, with different organisations working to slightly different timescales and for slightly different subsets of information. This needs to be simplified as a priority this year.
• Proportionate regulation. Trusts are concerned that care homes are increasingly risk averse, due to perceived fears around the CQC taking regulatory action. We encourage the CQC to work with the care market to explore how this can be addressed.

Long-term measures required

• Review membership of A&E boards. The membership and remit of A&E boards across the country is still too variable. The recent focus on A&E has also meant that key providers in the urgent and emergency care pathway, such as mental health providers, have not been fully involved in operational resilience discussions.
• Building relationships across the health and social care system. In many parts of the country, relationships between health and social care are positive. However, we need to strengthen these further at every level – individually, institutionally and system wide. Trust between individuals in particular is necessary to both shore up admission prevention and to support the safe and timely discharge of patients. All evidence points in the direction of effective relationships being key.
• Move planning focus from crisis management to prevention. The limited funding available for resilience planning locally has often focused discussions on discharge, rather than prevention. In many parts of the country, there is emerging evidence around the effectiveness of new models of care, aimed at reducing demand trends and ensuring patients are seen in the most appropriate settings. Only by balancing the need to invest in discharge schemes, as well as prevention initiatives, will operational resilience planning be effective.
• Providing a seven-day service across a local footprint. Admission avoidance and timely discharge can only happen if all organisations in the urgent and emergency care pathway have services available seven days a week.