Work planning for this winter certainly started earlier than in previous years – I was talking about it as chief executive of an acute trust as we were still in the middle of 2017 spring pressures. There has also been more input than ever before – my own experience and talking to colleagues currently on the front line suggests that comprehensive system-wide discussions and plans for managing winter pressures are now the norm across the service, crucially involving social care and voluntary sector organisations from the start. The plans have also benefited from the experience of, and input from, colleagues internationally and we have the National Emergency Pressures Panel sitting. The NHS has also been very active in engaging the public in its winter planning – the annual push on flu vaccination for the public and NHS staff, including the extension of the offer of free vaccination to social care staff for the first time; there have been campaigns to encourage people to use alternatives to A&E departments, including GP services that are available at weekends and over the holidays; and advice offered on how to manage coughs and colds without seeing a health professional.
So far so good, but as I said in my previous blog that is not how it feels on the ground to frontline staff, managers or – most importantly – patients. For all these groups the plan seems woefully inadequate if the measure of success is not just a better plan but a better set of outcomes for everyone.
Recent research may throw some light on one reason why this is. Work by Queen Mary’s University suggests that it is the increasing number of patients with long-term conditions rather than the shortages of GPs (and therefore less access to health care) that is driving attendances at A&E – in the study patients with at least four long-term conditions had an attendance rate six times higher than those with no such complications. The study also suggests that attendances at A&E departments have more than tripled in the past 50 years.
It is not only the number of people attending A&E that causes the pressure – the position with emergency admissions paints a similar picture. The most recent data from NHS England suggests that only once in the past eight weeks has bed occupancy across England been below 85 per cent, the generally accepted recommended level, and that was on Christmas Eve. It has only been below 90 per cent (the National Institute for Health and Care Excellence-recommended level) on four days and below 92 per cent (the NHS Improvement recommended level) on five days over that same eight-week period. These are truly shocking figures and mean with spikes in demand occurring regularly, hospitals are effectively consistently full in terms of acute beds. It is no surprise that patients are waiting, mixed-sex accommodation breaches are increasing, operations are being cancelled, and staff and patients are increasingly concerned about safety and patient experience. There is a real danger that everyone begins to normalise a situation that in previous years would have been unthinkable.
But doesn’t the NHS have the best winter plan it has ever had? That may be true, although the late identification of winter money, late decisions on mixed-sex accommodation breaches and deferred electives may suggest otherwise. Notwithstanding this, if the plan is not addressing the underlying causes or was set within narrow parameters of what was allowable by government, then it is likely to have been focused on a set of technical solutions when the NHS needs to be making adaptive and transformational change and this causes problems. It means that staff are working ever harder and better on the things they have previously done, struggling under a burden of ever-greater reporting upwards as the NHS and emergency care heads to the top of the political agenda, but are getting the same outcomes and not solving the problems.
While improving the way A&E departments work with the rest of a hospital and the wider health and care system is undoubtedly part of the solution, and encouraging patients to access alternatives to emergency care where appropriate is important, we also need to look at other more transformational developments. A focus on geriatric emergency care as in Norfolk, the emergency care floor at Western Sussex which is designed so patients benefit from the expertise of medical doctors, surgeons and older people’s care specialists working together rather than more independently in different departments, and the Northumbria specialist emergency care hospitals are all such examples. The premise that connects all three, and one that I support based on my experience, is that, with the strength of the A&E brand, changing population demographics and the rise in long-term conditions, rather than just encouraging patients to seek help elsewhere we need to properly invest in the type and scale of facilities that we need now and will need increasingly for the future.
This does not mean reducing the focus on demand management, out-of-hospital care and alternatives to A&E. Integrated care is still a crucial part of the way forward and some of the best examples of this are in the accountable care pilots such as Frimley Health which is starting to show some positive results in stabilising or reducing demand for emergency care. However, the NHS needs to look more fundamentally at the emergency care facilities, workforce and organisation it needs in and outside of hospitals. This could mean more specialist emergency hospitals, services focused on older people and people with multiple long-term conditions, as well as the development of sufficient step-up and step-down facilities and non-bed based services. It cannot mean just doing more of the same, thanking people on the front line while extolling the same people to do more and better without a real plan to transform how the NHS delivers care now and in the future.