Asssessment of readiness for 2019/20

Three factors leading to better performance

Trusts have highlighted three factors that they believe should help improve performance this coming winter:

• Collaborative working between health and care partners means that many systems are better prepared to respond to winter challenges 
  

  Trusts tell us that better system working across previously fragmented acute, mental health, community, ambulance, primary care and social care services, is supporting them to provide a more effective system response to spikes in urgent and emergency care demand. Partners are generally working together better to support people to remain independent, to ensure that more patients and service users are treated in the right settings, to be discharged from a stay in hospital in a timely manner, and to tackle capacity challenges collectively. Examples of the issues that system partners are now tackling together more effectively than in previous years include the capacity of out of hours primary care services, high levels of emergency admissions from care homes, and a lack of mental health crisis provision.

• Innovative approaches to providing care have helped create some extra capacity. 

  The creation and rapid expansion of the 111 telephone service has made a significant difference by acting as an initial triage point for 2,281,014 patients over the last two months – 7.1% more than the same period last year. Mental health trust leaders tell us they have sought to strengthen their support for crisis care, for example through enhancing liaison psychiatry support. Community service providers continue to develop innovative approaches to build capacity and support people to manage their conditions in the home where appropriate. Ambulance trusts continue to expand their ’see and treat’ approach which is designed to minimise unnecessary conveyance of patients to hospital. Acute hospitals have continued to expand their same day emergency care (SDEC)/ambulatory emergency care services which are designed to minimise unnecessary hospital admissions.
  
  

• Trusts also tell us that they have benefited from an effective national improvement offer to support urgent and emergency care performance.

  The NHS' urgent and emergency care planning, preparation and year-round improvement activity is more advanced and more comprehensive compared to three years ago. Although trusts would like to see less intensive monitoring for winter performance, they also report that central NHS winter planning has been further enhanced this year and that the new regional NHS England andImprovement teams are beginning to offer valuable support. Many trusts report that they have benefitted from a further year’s worth of all year round improvement and best practice sharing activity, supported by the NHS’ emergency care intensive support team (ECIST), which consistently receives very strong positive feedback.

Seven areas of concern

However, despite these improvements, trust leaders tell us they are more concerned than ever before about the level of risk they will need to manage for patients and their staff this winter. They have highlighted the following seven areas of concern:

• Demand for urgent and emergency care continues to rise – both in terms of volume and acuity.

  The NHS entered this winter with performance against the constitutional standards at an all time low. In short, the data suggests the system is close to the worst difficulties observed in 2017/18 despite relatively mild weather conditions.
  • Trusts are particularly concerned at the steep rise in demand for urgent and emergency care. Significant numbers of individual trusts tell us they are experiencing year-on-year increases of between 8-12% in emergency department attendances. The latest A&E data available for November showed that although the NHS is caring for more people, 81.4% of patients were seen within four hours, well below the 95% standard, and more people waited over 12 hours from the decision to admit, to admission.
  • There were more ambulance arrivals in week 1 of the winter sitreps than at any time over last winter.
  • Bed occupancy is a high risk with acute and general hospital capacity already running at 94.5%.
  • Given that the waiting list for routine operations has grown to the highest ever at 4.45 million, the impact on patients waiting for elective operations could be significant as trusts have to prioritise urgent and emergency care.

In addition to increasing numbers of patients needing care and treatment, trusts report an increase in the complexity and acuity of patients. Trusts tell us that it is very difficult to cope with this level of increase in demand given workforce capacity constraints and the constraints created by outdated estates and facilities. There is therefore widespread agreement across the NHS that an urgent and comprehensive analysis of the current increases in emergency care demand, and the reasons behind it is needed, to help the NHS understand and plan more effectively for the long term nationally, regionally and locally.

• Secondary care capacity is not keeping up with this growth in demand.

  After the longest and deepest financial squeeze in NHS history over the last decade, it is evident that the available capacity within NHS secondary care services is insufficient to keep pace with growing demand. Year-on-year growth is averaging around 6-10% across a wide range of NHS services including the ambulance sector, mental health, community care, routine operations, cancer services, diagnostic tests and in urgent and emergency care. For example, A&E attendances have increased by 15.1% over the past five years, A&E admissions have increased by 15.8% but the total beds available across the system as a whole has actually decreased by 3% in the same period.
  
  NHS provider trusts are treating more patients than ever before – 21 million A&E attendances and over 113 million outpatient appointments – and the innovations in care outlined in this briefing have helped grow some extra capacity but, fundamentally, there is a growing demand/capacity mismatch in secondary care. NHS England and Improvement must now work with local NHS organisations to properly assess the scale of that mismatch and, take a longer term, five to ten year, view, to address this growing gap.

• Primary and social care capacity is not keeping up with demand and both sectors have become more operationally unstable given the pressures they face.

  Trusts are heavily dependent on primary and social care to satisfy the vast majority of potential urgent and emergency care demand. The government has pledged to increase the number of GPs and to resolve the crisis facing social care for the longer term, however trusts generally report that their local primary and social care systems have been unable to expand to meet the extra demand they face in the short term. Given how many people are seen in primary care, small reductions in primary care capacity can translate into very significant increases in demand for secondary care services. Most trusts believe the primary and social care services in their local system have become more fragile over the last year. This is supported by evidence such as the broadly static number of GPs and another year’s growth in the gap between social care demand and funding. 

• The NHS is starting out in a much worse position this winter, compared to previous winters.

  The traditional NHS pattern has been to recover from winter pressures over summer and use the autumn months to prepare for winter. However, trusts and their staff report their busiest and most difficult summer and autumn ever, with little or no respite. As we set out above, performance against all of the access standards set out in the NHS constitution has already reached an all time low. In addition, there are concerns in some areas about how flu and norovirus may impact capacity.

• Systemic workforce shortages mean the NHS is struggling to staff services.

  Trusts tell us that they are working hard locally to staff services but also say that shortages across various professions and specialisms will make this winter more difficult than previous years. NHS vacancy rates remained broadly static year-on-year, and the current overall rate of 8.7% in Q2 2019/20 is only a marginal improvement on the previous Q2 figures in 2018/19 (8.9%) and 2017/18 (9.0%), with particular difficulties in some geographic regions and some professional specialisms.
  
  Trusts tell us that workforce shortages run so deep that, even where they could create extra physical capacity (e.g. open more acute or community or mental health crisis beds), they are increasingly unable to find the workforce required to staff them. The difficult daily challenge of finding the right number of staff with the right skill mix creates additional operational pressure and greater clinical risk in what are already overstretched services. This issue is, of course, compounded by a similar lack of workforce capacity in primary and social care.
  
  Thanks to the dedication and goodwill of NHS staff, the service continues to treat more patients every day, but reliance on this dedication and goodwill is becoming increasingly unsustainable. Sustained year-on-year increases in demand for services, along with a general increase in acuity and complexity means that staff have to work harder than ever. The vast majority of NHS staff work several hours a week unpaid above their contracted hours. The NHS is seeking to cover its current demand/capacity gap by relying on a large proportion of NHS staff working additional unpaid hours every week. However, many trust leaders are reporting that staff are reaching or have already reached a point where this is no longer sustainable. Staff are at risk of ‘burn out’ and being unable to work the extra hours being asked without risking their health and wellbeing.

• Current problems with the taxation of NHS pensions are also having a significant and important adverse effect on senior NHS consultants working the extra shifts on which the NHS has traditionally relied.

  The government, Department of Health and Social Care (DHSC) and NHS England and Improvement have listened to concerns raised by the NHS about the impact of the current pension tax arrangements. A series of temporary workarounds has had some, but insufficient, impact on addressing these issues. Trusts therefore face significant gaps in the senior clinical decision making capacity that is crucial to, above all, keeping patients safe and ensuring effective and timely treatment of patients. Senior clinicians are also necessary to ensuring patient flow through hospitals (e.g. enabling the right quality of emergency department front door triage and timely discharge of medically fit patients). Trusts are also concerned about the divisive nature of the current workarounds, and the impact on the recruitment and retention of talented managers and leaders who do not qualify for the flexibilities. In our view we need a workable solution for all NHS staff.

• Lack of dedicated winter funding.

  The NHS frontline is no longer receiving dedicated additional winter funding. The money previously dedicated to winter funding has been incorporated into mainstream budgets. Trusts report that this has effectively meant that this funding has become "business as usual, general, spending" and it’s almost impossible to determine whether it has or has not been spent on improving winter performance. Trusts argue that whilst dedicated winter funding often arrived very late in the day, in the past, it did give a helpful dedicated amount of money to fund extra winter capacity/performance improvement schemes.

In summary