Does winter ever end for the NHS these days? Helen McKenna talks about winter pressures in A&E with Siva Anandaciva and Matthew Kershaw from The King's Fund. Hong-Anh Nguyen reveals the most unusual question The King's Fund library service has ever received.
During the episode, Siva refers to a chart on emergency room waiting times. The chart is available here.
HM: Helen McKenna
SA: Siva Anandaciva
MK: Matthew Kershaw
HAN: Hong-Anh Nguyen
HM: Hello, welcome back. We’re here today for the second episode of the King’s Fund podcast where we talk about the big issues and ideas in health and social care. I’m Helen McKenna and I’m your host. Coming up later in the episode, we’re going to hear from one of the managers of our information and knowledge service, otherwise known at the King’s Fund Library about the sorts of questions they get asked to research by the public, including I think, the most unusual question they’ve ever been asked but before that, we’re going to take a look back at this winter and how the NHS coped with it and also think about whether the winter ever really ends of the NHS or whether these days we’re just in a perpetual state of never ending winter.
HM: To help us with this, we’re joined by two of my colleagues here at the Fund, Siva Anandaciva and Matthew Kershaw. Siva and Matthew, if you could introduce yourselves and cover three points please. So firstly, tell listeners what your role here at the fund is, second of all can you tell what qualifies you to be here today talking to us about winter and also thirdly maybe something people might not necessarily know about you. So maybe a personal secret. Siva, why don’t you start us off?
SA: Great, thank you. So, my role here at the King’s Fund is chief analyst in the policy team so I cover things like funding, finances and performance and all of these things are related when it comes to A&E. What qualifies me? So, I’ve been talking about winter for what seems like forever, but is close to about ten years now. About ten years ago I working in the Department of Health on urgent and emergency care performance and at that time someone said, listen son, every five years we try and reinvent the wheel and do the same things over and over again, and I think when it comes to urgent care policy things like A&E that is slightly true and I continued into my next job at NHS Providers, an organisation that represents hospitals, also covering winter and pressures on hospitals, ambulance services in the NHS. So it feels like I’ve been talking about winter for a while, if that qualifies me to talk about it a little bit longer and in terms of a personal secret, there is nothing I can share over the airwaves, so instead I will talk about another thing that qualifies me to talk about A&E which is my personal experience of it. I am a heavy user, having broken my wrist, my arm, my shoulder blade, my spine and at least one other bone that I can’t remember. My kneecap, that was it. All of which involved me using or passing through A&E.
HM: Great, thank you for that Siva. Matthew, tell us about yourself.
MK: Okay, I’m a senior fellow here at the King’s Fund and I’ve been here for about six months. Previous to that I’ve worked for the NHS about 25 years it’s my quarter century anniversary this year and I think that helps qualify me for this conversation because I’ve spent a lot of time operationally, strategically and then as chief executive in three Trusts, managed winter and the winter pressures and all things that hospitals do on a day to day basis. So I’ve got lots of real experiences to bring to such a conversation. In terms of a personal secret, I’m trying to learn to sing this year, that’s one of my new resolutions for this year. I’m struggling to get on with it but I am making some progress.
HM: Fantastic, so perhaps you can sing to us about winter pressures in this episode.
MK: That’s a horrible thought.
HM: Okay, so, let’s start with how bad this winter was for the NHS, because I guess if you look at what the media was saying, I get the impression that it really was the worst winter ever and maybe that’s the case but we saw images of ambulances queuing up and trollies stacked up in corridors. Siva can you tell us what the data actually says?
SA: Sure. So on the one hand, I can’t remember a time when the NHS has said, you know what that was a great winter. It was one of the best on record, so it always feels like an annual competition for was this one of the worst, but I think, you know you mention data, we do have some data and that suggests it was a different winter. So I’m looking a stat in front of me here, 76.4% of patients were seen within four hours in type 1 A&E departments. Now that’s important because we have a national standard for 95% of patients to be seen within four hours, it’s probably the totemic standard of the last 10-15 years. It was a sign of all the public and patients we get in return for additional money flowing into the system. So to slip back so far to the extent that just under three quarters of patients are seen in four hours is a real indictment of the pressures that we’ve experienced this winter and what’s unusual is, we’ve got this poor performance in waiting times but we haven’t had a massive flu outbreak. It wasn’t an easy winter, but we still haven’t seen the types of norovirus, influenza, winter vomiting bugs, all these things that normally really wreck your winter plans. So that suggests that the NHS is just having all these performance issues because we haven’t given it the resources it needs to cope with winter pressures. So I think that, that is one stat that leaps out at me, but a second stat and probably the final stat I will bring today, is 9 of 137 NHS hospitals running major A&E services met the standard in the last month. So that’s only nine organisations that have seen patients within four hours. When I was working in the Department of Health you could count on one hand the number of places that were filling the standard and now you can just about count on two hands the numbers of places that are meeting it. So that shows how far we’ve fallen in quite a short amount of time really.
HM: So Siva, I think you were talking about March data just then, do you think we’re going to see that improve over the rest of the year or is it right that we’re now looking at an NHS that is in a sort of perpetual state of winter?
SA: So you’re right, those figures I provided were for March 2018. If we were talking a few years ago, I’d say I’d expect performance to start bouncing back but I think the last year or two has shown us that that won’t be the case going forwards. I think the service A&E department, ambulance services will remain under pressure as we stretch into spring and summer. This is where all the quotes about the NHS being in Nania, you know it’s a winter that never ends and there’s no Christmas either are true, and that’s because in the past you can definitely see the surge in activity over winter and then systems would recover as Easter approaches. Activity particularly demand for admissions to hospital, the really serious cases would start to tail off and performance would start to creep back up. Now what we seem to find is something very, very different which is, you have your winter pressure, you get hospitals get swamped with demand, ambulance services get swamped with demand, waiting times increase and then you don’t get that bounce any more in summer, you don’t get that bounce in spring and services aren’t recovering and that suggests it’s not necessarily a problem with demand, more people needing care, it’s a problem with supply. Do we have enough hospital bed? Do we have enough staff to provide care? And if you don’t that’s when you’d see year round performance as pressured as we’ve seen it.
HM: What are some of the other drivers that are resulting in hospitals feeling the pressure so much?
SA: I think you could, so why are hospitals under pressure? You can divide it at its most basic level into supply and demand. So on the one hand you have got increasing demand, so something like 2%, 3% a year attendances go up at A&E departments which would be fine if we were increasing the number of nurses, doctors, hospital beds to cope with it or if we were getting more efficient in how we treat these patients, and what you’re seeing is the service is trying to improve how it deals with patients but you’ve only got so many staff, it’s not growing at the rate you need to keep pace with demand and that ends up in the place of hospital departments, A&E departments that were built to see 60,000 people a year seeing 100,000. The numbers always change but the message is always we’re seeing double what we were built for.
HM: Okay. Matthew, you’ve been a chief exec of a hospital, I’m assuming including during the winter, what does it feel like when you’re managing winter pressures?
MK: I mean I think there’s a bit here which is, you’re managing pressures consistently but, and therefore there’s always a level which the pressure is on. The pressure is on from a number of fronts. So you feel pressure yourself, because you want to do the best you can as the chief executive to, you know, run your organisation the best way you can. You feel pressure from staff who you know, you see them, you talk to them, you feel the pressure and the concern that they have about some of the things they’re having to do and some of the environments that they’re having to do that in. You see pressure from patients and the public who you know, walking through a waiting room when people have been waiting for a long time and got forlorn looks on their faces or they’re sitting on the floor because there’s no chairs. You know, when you’re the person ultimately responsible for that, one thing it doesn’t feel is good. You know, you feel embarrassed, you feel upset for them, you feel like you just want to make it better tomorrow and you know you can’t. But you also get pressure from you know, colleagues you know in the Board. You get pressure from external environments, from the local media, from politicians, from the regulators. You know everybody wants this system to be working better and if you can’t make it so, then that pressure does come to a lot of people and the pressures are different for different groups of people. So if you’re a staff nurse in A&E and you’re trying to manage you know, twice as many patients coming through your doors on a particular day than the department has actually been built for, that’s a hell of a lot of pressure to face.
HM: And how does it feel as a chief exec walking round the hospital and seeing with your own eyes that clearly patients aren’t getting the experience that they should get?
MK: I mean, I always felt a number of things. Firstly, strange thing to say but, proud of the staff who were working exceptionally hard in sometimes, almost impossible circumstances to try and do the best they possibly can and despite all of the pressures and the figures around statistics, I personally still think, you know that quality and the responsiveness of our emergency care is, compares pretty well with what’s happening around the world. Now I’m not saying that’s good enough, we want to be better, but I still think there’s a lot of pride that we can have in what people are doing.
HM: So Matthew, you mentioned that actually internationally, the NHS does quite well in comparison to other countries, despite the pressures that it’s currently experiencing. Siva, what does the data say on that? How do we compare with other countries?
SA: So the NHS compares very well with other countries and I think this is one of the things I really struggle with, because on the one hand every winter, we’re called in and asked how back is A&E performance and I do my bit, saying well it’s you know, under a lot of pressure and performance is sliding but if you look back there are three things that provides some helpful context. One is the international comparisons you just raised, so I printed it out but it’s a podcast so actually that chart is pretty useless but there is a helpful chart that compares waiting times for A&E in this country with Canada, with Switzerland, with Norway, with other countries that we think of with similar health economies and we come out incredibly well. A very small proportion of people wait for emergency care over five hours compared to the other countries on this list. I could try and describe the chart but let’s just say, we’re better than Sweden, better than France, better than New Zealand and better than Australia and the United States. So internationally, we compare well on A&E waiting times. The second thing is over time. So I know I talked earlier about how performance has slid in recent years but you compare it to 15, 20 years ago. I remember someone telling me, someone who works in a Trust he was telling me the Time sent in their war correspondent to cover the A&E department, things were that bad in terms of how long people were waiting. So you look internationally, you look over time, in the long run and we’re doing relatively well in A&E performance, and the final thing is, you ask patients how long does it feel you’ve been waiting in A&E? Do you think you were seen quickly? Are you happy in terms of recommending the service to friends and family? And despite all these pressures, despite the media commentary, despite the commentary I give, patients are broadly happy with the service they get. So that’s one of the hard things to reconcile. The pressure’s absolute real but we’re comparing well internationally. We compare well with the past and patients like the service that is being delivered, and that’s one of the things we have to find our way through.
HM: Often the focus in winter is on hospitals and then when other services, general practice, community services are discussed it’s about the sort of the shortages or lack of provision there that is making an impact on hospitals and maybe you could cover that, but also what does winter look like for those services? Presumably they’re also under pressure?
SA: I think it comes back to this totemic point. So absolutely, all services primary care, community services will experience pressure from winter and absolutely the purpose of a GP, a GP doesn’t exist simply to take pressure off a hospital, but we spend so much and so much money investing in A&E services and that was the offer, that was the deal to the public, you will get quick access to care. I think the fact that A&E literally swallows up all the oxygen in any room when you talk about winter shows how far we are from this new vision where we have an NHS more focussed on keeping people well, keeping people healthy than treating them quickly when they get ill. It just shows how far we’ve got to go.
HM: Where does money feature as a driver, because in the autumn budget last year the government announced some extra, I think it was £300 odd million for the NHS to tackle or support it during winter and obviously we then went on to see all the pressures as we’ve just discussed. Did that money, was it too late in the day for the NHS to use it or, why didn’t that money go further in terms of improving the situation?
SA: So there is a long tortured history in the NHS, that what we call winter funding but in various years has been called resilience funding or I don’t know if Matthew can remember any other things, but it all had a common feature which is it comes out around autumn when it’s very late in the day to spend it and the system is suddenly flooded with cash. So I’m running an NHS hospital, suddenly I’m invited to bid for funding to help me manage winter. Well, it’s very late in the day for me to find new staff. It’s very late in the day for me to redesign how I deliver care. It’s very late in the day for me to go and buy capacity for beds in residential nursing homes. So I think you’re right that the lateness of when this funding arrives, whether it’s enough funding in the first place, are all issues that limit its effectiveness, and the other thing is I could give the most challenged hospital, the most challenged A&E department all the money in the world, that’s not going to solve this problem if it can’t recruit the staff it needs to deliver the care, if it hasn’t got enough hospital beds to admit patients. So these are all factors that limit how far the money will go, even if it came on time.
MK: I’d concur with Siva’s comments. This year, as in previous years, too late for it to help with transforming a service and too high an expectation that it will quickly. So you’re a, put yourself into the shoes of a politician, we’ve just given the health service another X millions of pounds, we want that to make a difference. So there’s a huge expectation that it’s going to, but it’s too late to actually effect real change on the ground. So, you get potentially the worst of both worlds. The politicians feels like they’ve gone the extra mile to create some more money, the NHS having asked for more money gets it. The politicians then think well it must get better and the NHS is saying, yeah but you’ve got to give it to us early, you’ve got to give it to us in a different way because that’s not actually going to help us. So both groups of people feel like they’re not getting what they want from that conversation. The net effect being, the service is from the patient’s perspective and from a staff’s perspective don’t move and it just feels like the same and it feels like there’s money being poured in with no real benefit coming from it and so, is money a factor for sure it is. It’ll be really interesting to see what happens with the long-term settlement, because if the long-term settlement comes up with something that gives transformation funding and gives it over a longer time period with an expectation it’s going to take a period of time to deliver real sustainable transformational change, that’ll be a fantastic thing.
HM: So Matthew, you brought us on to the idea of sort of solutions for the future, and both of you have mentioned these issues around workforce shortages and the role they play in increasing the pressures on hospitals. Obviously, there’s the workforce strategy I think coming up over the next few months, what do you think are the solutions for making sure that this last winter doesn’t happen again this winter? Or do you think we’re already too late?
MK: I mean from a workforce perspective, to expect the winter of 2018/19 to be massively different in terms of the workforce that we’ve got, can get, I think is unlikely to change. It’s going to be basically what we have this year just gone. And that’s a slight danger when you know, any number of politicians stand up and say we’ve put money aside to recruit X thousand extra whatever they are, I think there’s a misunderstanding and I can understand why it’s so, but there’s a misunderstanding that that means those people are going to appear tomorrow and be active the next day and the service will be different by the weekend. You know, the public, it’s not explained in the way that says, well this is going to take a decade to get right because that’s not a timeframe that really works in these circumstances, because everybody wants quick immediate answers to what are longstanding difficult problems. So I would personally say in short answer, it’s likely to be much the same from a workforce perspective this year and if we’re not careful, next year unless we start making big decisions now and the workforce strategy is clearly a big part of that.
HM: So, actually what you’re sort of saying is that at best we might see things improve in terms of pressures and particularly winter pressures for patients from about 2021/22 onwards. If action is taken now. Siva what are your thoughts?
SA: So I think if you’re trying to improve A&E performance and you realise staff and the workforce are a huge part of that, you’ve got to think long term. You’ve got to think about is it an attractive career? You know, if I was advising someone I think emergency doctors and nurses are worth their weight in gold but you can’t do any private practice. You have to work long hours, you have to retire at the same age. You can’t get early retirement, even though you’re on your feet the whole shift. So, there’s got to be some thought about how we incentivise people to move into this profession and obviously we’ve got to get enough people trained to be emergency care physicians, nurses all of that’s great, all of that’s long term, all of that’s important. None of it will help solve the winter crisis that we’ll start talking about here in about four months’ time. So I think either you’ve got to accept that performance is going to stay broadly where it is, or you’re looking at changing the tactics you have and one of the things, this isn’t official King’s Fund policy, but one of the things that I think it’s interesting to look at is, it’s a national health service at each hospital at the moment, each service holds onto its own emergency care staff as its own resource. If you start thinking, should we be a bit more flexible, should we see if we’ve got people in the right place, and maybe sharing staff where needed over a region to even out supply, to meet demand a little bit better, is that one of the things we should look at. That’s the sort of tactical approach I think we should be more open to if we really want to improve performance.
HM: And just briefly, what about learning from elsewhere. Are there other parts of the country that this winter did manage okay and what can we learn from them?
MK: I’d say if we could create a bit more headroom for people to have that time and space and energy to actually direct effort into improvements and innovations and not be feeling like you’re firefighting every day or reporting a whole load of stuff to increasing numbers of regulators or fending off questions from politicians and the media, then we’d actually have a better chance of making some of those improvements that could and should be made now in advance of more transformational change, but the lived experience of most frontline clinicians and senior managers in the system, when it gets into real distress is that you have no time at all for that, and that’s a real problem.
HM: So thank you both for offering your views today and it sounds like there’s still a long way to go before winter in the NHS is solved. Thanks both.
MK: Thank you.
SA: Thank you.
HM: If you’ve been to the King’s Fund building before you might have seen that we have a wonderful library officially known as the Information and Knowledge Service. Today we’re joined by Hong-Anh Nguyen who is one of the service managers. Hong-Anh, can you tell us about what you do and a bit about the service.
HAN: We are the library for the King’s Fund. We support people here, people like yourself in the research and the work that we do but we are also unique in that we’re a public library as well so for anyone out there who has a question about health or social care policy, we’re here to support any needs. We get questions from all sorts of people, so we get questions from the public, we get questions from researchers, academics, people working parliament or government and also the media. So a really broad range of people all with like different research needs and wanting to know different things about the system. So we get about 1,600 enquiries a year and half of these are kind of in depth research enquiries and the number is rising. So definitely people are more interested in knowing more about the system.
HM: Okay, and so are you going to run through a couple of the sorts of questions that people ask?
HAN: Yeah, so I’ve brought along a couple of the questions. This is a question that came from our recent health and care explained event. We had people submitting questions on an app during some of the sessions and one of the ones I picked up on as the question that when I saw it, I thought actually I don’t know the answer to that either and it was during our social care session and someone submitted a question about the social care green paper and they wanted to know what exactly is a green paper. So in health and social care, or in government policy, we very often have green papers and white papers. I think you might know a bit about what the difference is?
HM: So my, you’re going to correct me I assume, but my take would be that a green paper is where the government is asking more of a genuine question of stakeholders and the public about a policy issue. So where they’re really trying to gather information and ideas because they haven’t yet developed fully their policy proposals. Whereas a white paper, I think, would be where the government has developed quite thought through policy proposals and is consulting more in a kind of a because they formally have to and they might revise their proposals a little bit but they’re basically preparing to lay legislation down for those, for the new policy and it’s pretty much thought through and almost defined.
HAN: So, gold star to you. That’s generally right.
MH: Thank you.
HAN: You’re looking very happy right now. So yeah, generally the green paper is when there’s no real firm proposals and it’s much more exploratory. It’s not as far down the line as a white paper. So white paper might include something like a piece of draft legislation or a draft bill, so yeah, they’re kind of just at different stages in the journey of policy making.
HM: So can I just check something? I should know because I used to work in the Department of Health but I can’t remember, maybe because I never saw a green paper when I was there, is there a difference in the paper that these green paper, white papers are published on? Is it a matter of green papers on green paper?
HAN: As far as I know, no but I’d need to go and check, but I don’t think they are.
HM: Okay, maybe one of our listeners will message in and tell us.
HAN: Maybe historically it might have been but, no I’ve not seen a green paper in a while either, so maybe.
HM: I look forward to finding out. Just one last question for you and that is, what is the most unusual question you’ve been asked in the library service?
HAN: We get a large range of questions. The ones that spring to mind are, why doesn’t the NHS try and generate more income by selling medical marijuana? That’s quite a tough one to answer. It’s probably not for me to answer.
HM: What do you answer?
HAN: I don’t know the economics of the marijuana trade, so it’s difficult for me to see what the cost effectiveness and the income generation that might bring to the NHS. The other one that springs to mind was from a television researcher who wanted to know, how many people who go to A&E are there because of a sex related injury?
HM: And the answer?
HAN: We don’t know.
HM: Because it’s not recorded, is that?
HAN: Well so in the data the diagnosis is recorded but not the reason why. So we could look up how many people maybe have a back injury at A&E but they’re not all necessarily going to have been there because of a sex related injury. So difficult to say basically. The only source of data is the Daily Mail Pole.
HM: Which asks people about their own experiences?
HAN: Yeah, so it’s self-selecting sample there.
HM: Okay, but obviously what you are saying is that the library service does not judge any question, that all questions are good questions and valid in themselves?
HAN: Yes. No judgement.
HM: Well thank you Hong-Anh and what I do want you to tell listeners now is, just how they can submit questions to you if they have any and they’d like us to cover it in a future episode.
HAN: So you can Tweet us @The King’s Fund or you can email us at [email protected]
HM: Fantastic, and we will anonymise the questions if people want that to happen.
HAN: Yeah and if they want to ask another sex injury related question.
HM: Fantastic. Thank you Hong-Anh.
HAN: Thank you.
HM: Well that’s it from us for today. Thanks for listening and if you enjoyed it, please subscribe and tell your friends about it and if you have feedback or ideas for topics you’d like to hear covered in future episodes then please get in touch either on Twitter @The KingsFund or my account @HelenaMacarena or you can leave feedback on our website which is www.kingsfund.org.uk or via the podcast email box that Hongan just outlined which is [email protected].
HM: Good bye for now and hope you can join us for the next episode of the King’s Fund Podcast.
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