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Demand and activity in the NHS: still rising

As we publish our new briefing, Richard Murray considers the wider context of increasing demand and activity in English hospitals.

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Our briefing looks at the increase in activity in English hospitals over the past 13 years. It shows that recent increases in demand for treatment are nothing new – on the contrary they are broadly in line with the longstanding trend. What is remarkable is how widespread and sustained these increases are across emergency admissions, elective admissions, outpatients and A&E attendances. Perhaps the only oddity is diagnostics, where the growth is even higher, with activity having doubled since 2006/7.

We wish it were otherwise, but the availability of data means we have focused on hospitals to the exclusion of other services. Other parts of the NHS including general practice, mental health and district nursing have also been experiencing significant pressures. However, waiting time standards – for 18-week referral-to-treatment, A&E, diagnostics, and cancer – provide a degree of protection for patients in that those who need treatment in hospital generally get it within a reasonable length of time. This is not necessarily the case in other key services experiencing problems with access and quality of care. Even within hospitals, where in the days before tighter targets were introduced making patients wait longer for non-urgent treatment was a classic way to reduce activity and spending, recent increases in NHS waiting lists and waiting times may yet signal a return to the bad old days.

Rising admissions would be easier to deal with if patients could be discharged quickly. Indeed, in most years the average length of stay in hospital has fallen, freeing up staff and beds to deal with new arrivals. The combination of reductions in average length of stay and a switch to day-case surgery has meant the NHS has often been able to manage demand and reduce the number of hospital beds. However, as NHS Digital has noted, the average length of stay has reduced only slightly in recent years, providing little relief from rising demand. With the number of days lost due to delayed transfers of care also rising by more than a quarter in 2016/17 so far, any significant further reductions in length of stay are unlikely until the wider health and social care system is able to provide better and faster care outside hospitals.

With rising admissions and growing delays in discharging patients, we might expect very high bed-occupancy rates. This is exactly what we are seeing, with record levels of bed occupancy in mental health and occupancy levels for acute beds at their highest-ever level for the time of year. It would be an understatement to say that this is a difficult starting point for any sustainability and transformation plan aiming to reduce the number of hospital beds between now and 2020.

Rather than a step-change in the rate of growth in demand, it is the slowdown in funding (along with the additional staff it has paid for) that is the key reason for the financial and operational pressures facing hospitals. Between 2003/4 and 2010/11, funding for the NHS rose at an average rate of 4.8 per cent a year in real terms. However, since then it has been growing at an average of just 1.2 per cent a year, where it is likely to stay until 2020/21. Based on current spending plans, the NHS cannot expect to manage rising demand and maintain standards of care.

This emphasises the importance of finding ways to moderate demand and to make sure patients are treated quickly and efficiently once they are admitted. As well as building on innovations in the care of older people in the UK, this means learning from international examples – such as the Nuka system of care in Alaska and the District Health Board for Canterbury in New Zealand – which have had some success in moderating demand. It also means fulfilling the promise in the NHS five year forward view to radically upgrade prevention. Alongside the critical role of local authorities and the NHS, the government should make more use of the levers at its disposal including regulation and taxation. With this in mind, it’s encouraging to see the government following through on its plans for taxing sugary drinks, even if it has ignored other levers for tackling childhood obesity.

Some measures will take a long time to bear fruit, at least at national level. In the short term, along with continued efforts to deliver the savings outlined in the Carter review and other efficiency plans, the best hope may lie in reviewing and improving how services work in the community. This is a challenge given the evidence that in recent years, despite the rhetoric about moving care out of hospital and closer to people’s homes, the system has instead reinforced its financial and operational focus on the acute sector. As well as understanding what services the NHS should provide to best meet the needs of the population, we also need to understand how to get there. With the current mix of deficits, operational challenges and shortages of both staff and beds, the risk is that both the what and the how get crowded out once again.