NHS trusts are experiencing record levels of demand for their services. Many trusts are now running at capacity levels beyond the recommended norm and levels in other western systems. This is contributing to local health systems being less resilient and some being unable to cope with surges in demand. This was exemplified by one of the toughest winters the NHS has faced, with performance against waiting time targets dropping sharply despite the best efforts of staff operating under intense pressure. Other performance targets across the system are under similar pressure. For the first time, the NHS is now missing all four of its key targets: 75% ambulance response, 95% A&E four-hour, 92% 18-week elective surgery and 85% seen within 62 days of GP referral for cancer. The evidence on quality is mixed – while patient satisfaction with the NHS remains high and some trusts, despite the unprecedented pressures, are improving, the NHS faces serious challenges in maintaining standards of care.
The provider challenge
Rapidly rising demand and pressure on access to services
The NHS continues to experience sharp increases in demand for hospital, community, mental health and ambulance services. Increasing demand is being matched by increasing acuity. Although there are early signs of new care models starting to make an impact, these are at a small scale, so system level demand continues to increase rapidly.
For example, in total, A&E departments in 2016/17 saw attendances increase by 3%, and 3% more patients were admitted to hospital. These levels of demand are beyond the assumptions made in the NHS Five year forward view.
NHS provider capacity, including staffing levels, is broadly fixed. Despite their best efforts, trusts are therefore struggling to meet this extra demand and data from the winter period shows that performance against key targets has slipped further and more sharply as a result.
In December 2016, only three out of 139 trusts with a major type 1 A&E department met the standard of admitting, transferring or discharging patients within the four-hour target. Performance reached the lowest on record in January 2017 – down to 85% for all types of A&E and to 78% for the largest A&E departments. The last time the standard was consistently met for all types of A&E was in 2013/14. There have also been significant increases in the number of patients waiting longer than four hours before being admitted from A&E to hospital – so-called trolley waits. Between October and December 2016, 164,555 patients waited more than four hours for a bed – this is 66% more than the same period in 2015. This is a good indication of increasing patient safety risk.
Performance across all targets is under pressure. The target for 92% of patients to start consultant-led treatment within 18 weeks dropped to 90% at the end of March 2017 - the lowest end-of-year performance since the standard was introduced in April 2012.
Ambulance response times are also on a downward trend. There has been a steady decline in the proportion of calls attended within the eight-minute target for Red 1 and 2 calls (67% and 59% in January 2017 against a target of 75%). The target for Red 1 calls was last met in May 2015.
The recent decisions to relax the performance trajectories for the four-hour A&E and 18-week elective surgery targets in 2017/18 are therefore a simple recognition of reality. However, even the new A&E performance trajectory will be stretching and difficult to achieve, as The King’s Fund survey of frontline NHS leaders recently concluded. In its latest survey, almost half (49%) of trust finance directors and 60% of clinical commissioning group (CCG) finance leads were either fairly or very concerned that the NHS will not be able to deliver the revised performance trajectory (from 95% to 90%) by September 2017.
Our survey found that almost half of chairs and chief executives (47%) expect their trust’s performance on waiting time targets to improve over the next six months. More than a third (37%) thought performance would stay the same; while just over one in 10 (13%) said they would deteriorate.
All of this will impact patient care. As we said in our report earlier this year, Mission impossible? The task for NHS providers in 2017/18, not meeting the 95% four-hour A&E target means that patient experience and safety in urgent and emergency care will be adversely affected. Not meeting the 18-week elective surgery standard means that more patients will have to wait longer for elective surgery. And in other critical areas, such as cancer care, despite their best efforts, trusts have been unable to meet the standard of 85% of patients having a first treatment within 62 days of an urgent GP referral. Clearly this also carries patient safety risk.
Increasing risk from higher occupancy levels and lower resilience
As the mismatch between rising levels of demand and the NHS’s relatively fixed capacity grows, two major issues emerge: unsustainable bed occupancy levels and growth in the number of local health systems that are less resilient.
First, bed occupancy levels are now regularly well above the recommended safe level of 85% for all weeks during the winter period, peaking at 96%. Bed occupancy figures reached 88% for the October-December period – this is the highest ever recorded levels since quarterly data began in 2010/11. Exceeding the 85% recommended level is associated with much greater levels of patient safety risk. As the National Audit Office has noted, regular bed shortages, periodic bed crises and increased numbers of healthcare-acquired infections are all more likely to occur in hospitals with average bed occupancy levels above 85%.
One key driver of increased occupancy levels is the rising number of delayed discharges the NHS is experiencing. In January 2017 there were 197,100 total delayed days, up 23% from 159,600 a year earlier. This affected more than 7,000 patients who were medically fit for discharge but were delayed from leaving hospital - the highest since monthly data began in August 2010. There are many reasons for delayed discharge, but the proportion due to issues with social care increased to 40% in March 2017. However, delays within the NHS family remain the largest category.
High occupancy levels can mean that hospitals become much less efficient, which in turn leads to more cancelled operations. These reached record levels over the winter. During the quarter ending in December, 21,249 patients had their operations cancelled for non-clinical reasons. This was up by 2,856 patients for the same quarter in the previous year.
Running at these occupancy levels means lower levels of resilience and more trusts that are less capable of coping with surges in demand, as the increased number of trolley waits and ambulance handover delays showed this winter.
Increasing pressure on quality of care
Any analysis of NHS care needs to be placed in the broader context of the continuing significant improvement in patient outcomes. Better prevention, earlier diagnosis and innovative new treatments are leading to better survival rates for conditions such as cancer, stroke and coronary heart disease. For example, stroke death rates in the UK fell by almost half in the period from 1990 to 2010 and 10-year cancer survival rates have been improving steadily, although they are often still lower than in comparable countries.
However, in its report on The state of care in NHS acute hospitals, which is based on inspections of all 136 NHS acute trusts and all 17 specialist trusts, the Care Quality Commission (CQC) argued that “the scale of the challenge that hospitals are now facing is unprecedented – rising demand coupled with economic pressures are creating difficult-to-manage situations that are putting patient care at risk”.
Evidence on the degree and extent to which pressures are affecting quality of care is mixed. In its most recent annual report on care quality, the Nuffield Trust and Health Foundation concluded that care quality is being sustained in several areas such as public health, stroke care and patient satisfaction, but they also noted a recent slowdown in the progress towards eradicating healthcare-associated infections. However, in a separate report the Health Foundation concluded that it is too early to tell whether rising pressures on the NHS are affecting the overall quality of patient care. They also pointed to important gaps in our understanding of care quality in areas such as community services.
Informed by a near complete set of inspection results for all trusts, the CQC inspection data is also mixed. Of the 235 NHS trusts in England, 231 have now been inspected and rated with a majority of trusts rated as either requiring improvement or inadequate. Fourteen (6%) were rated outstanding; 91 (39%) were rated good; 113 (49%) were rated as requiring improvement; and 13 (6%) were inadequate.
The CQC has concluded most hospitals are delivering good quality care and looking after patients well, even though they face constraints. They found many trusts have shown they can improve despite their challenges but that some trusts – even those rated ‘good’ – had blind spots in particular core services. They argued the best trusts balance money and quality effectively but that too few trusts have an effective patient safety culture in place. They also found leadership to be key, with successful trust boards working hard to create a culture where staff felt valued and empowered to suggest improvements and question poor practice. However, in their view, too few trusts listened effectively enough to staff.
Patient safety remains a concern, with 81% of acute trusts rated ‘inadequate’ or ‘requires improvement’ in this domain. However, the CQC found the majority of people are treated with compassion, dignity and respect with 93% of trusts rated ‘good’ or ‘outstanding’ in the caring domain.
The CQC’s latest inpatient survey indicates that patient perceptions of the care they receive are still strong, with some small but statistically significant improvements in a number of questions compared to recent years. This includes patients’ perceptions of the quality of communication between medical professionals and patients, the standards of hospital cleanliness and the quality of food. However, patients’ perceptions were less positive when it came to waiting times, being involved in decisions about their care and treatment, information sharing when leaving hospital, and support after leaving hospital.
Responses to our survey of chairs and chief executives reinforce the mixed picture outlined above, with 61% saying they are confident their trusts are currently able to provide high quality care (this was 64% when we last surveyed them for our report in November 2016).
There are a number of initiatives underway to improve quality of care, but it is too early to tell whether they will consistently deliver systematic improvement. These include quality special measures, where success has been varied. All of the trusts that were originally placed in the regime have now demonstrated sufficient improvements to emerge from it. However, some trusts have stayed in the regime far longer than expected, while two trusts have re-entered. This suggests the scheme is not working as effectively as it should be. Fifteen trusts remain in special measures.
Five NHS trusts are embedded in a five-year partnership with NHS Improvement and the Virginia Mason Institute in order to support them to develop a ‘lean’ culture of continuous improvement which improves patient care.
Other improvement initiatives, such as the national emergency care improvement programme and A&E delivery boards, are helping trusts to cope with demand more effectively. However, we are waiting to see whether these initiatives support a return to the 95% four-hour A&E constitutional target.
Tackling variations in care quality
The persistence of variation in the quality and standards of care that exists within and between trusts – as evidenced by the CQC, remains a concern. There are many causes of unwarranted variation, and some will be legitimate, for example when adopting innovations.
Trusts report that rapid elimination of unwarranted variation is often more difficult than might be immediately apparent. Reasons for this include: the need to validate outlying data; clearly establishing the reasons for variation; designing a change programme to tackle these causes; ensuring appropriate clinical alignment; and then delivering what is often a complex set of changes. This all needs to be achieved at a time when analytical, change and project management resource has been scaled back and management bandwidth is at a premium.
What providers need
- NHS trusts need a smaller number of priorities, with a realistic delivery trajectory for each. A new government has the opportunity to review what is being asked of the NHS within its available resources.
- While we welcome the new performance trajectories announced by NHS England for the key four-hour A&E and 18-week elective surgery targets, trusts would prefer to be properly funded to meet all the standards outlined in the NHS Constitution. As we noted in a recent article in the Guardian, a lower elective surgery target will not make it easier to recover A&E performance and even the relaxed trajectory looks challenging.
- We need to ensure patient safety risk is appropriately resourced to manage the pressures the NHS will face next winter. The government’s strategy of creating NHS capacity through the extra £1bn social care funding allocated in the budget only offers a partial solution. More capacity and a longer-term approach will be needed.
- Trusts report they lack the capacity and capability to reduce unwarranted variations in performance. NHS Improvement needs to review what support and investment is needed to drive the required changes at trust level.