Here’s hoping the worst of winter weather is behind us! With warmer weather this month, most people will be hoping that the pressures will start to ease for the NHS and frontline staff. But we are not out of the woods yet.
For NHS leaders, and the government, it is time to start reflecting on what has been another extremely challenging and highly pressured winter for the NHS. Weekly reporting of winter performance might be at an end, but it would be naïve to think that the pressures which traditionally define winter in our health service will melt away with the snow. This strain is now an all-year event.
Our view is that the NHS planned more extensively and meticulously for winter than ever before – both locally and nationally. This included supporting the most challenged systems, allocating £335m in extra winter funding in last year’s Budget, and setting up the National Emergency Pressures Panel to deliver more joined-up advice for trusts. But we need to put these efforts in perspective. The NHS, at national and trust level, could only plan with the resources it has available.
We entered this winter facing real challenges. Bed occupancy was already running at an average of 94.5% for the last week in November, so there was precious little slack in the system. This was coupled with warnings of potentially the worst flu outbreak in the last decade.
Our view is that the NHS planned more extensively and meticulously for winter than ever before – both locally and nationally.
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The service faces severe funding and staffing shortages. The latest quarterly performance report from NHS Improvement illustrates these pressures, with one in 11 full-time positions across the NHS vacant by the end of December 2017. This is putting intolerable strain on the existing workforce. There is also evidence that progress in reducing provider deficits is starting to stall, with trusts struggling to match the resources available to growing demand.
The most recent British Social Attitudes survey, published in late February, showed a fall in the level of public satisfaction with the NHS and social care; the reasons cited were workforce and funding pressure. There are also worrying signs from the 2017 staff survey, with staff engagement declining and the levels of work-related stress increasing.
The difficulties experienced by frontline health and care services this winter should be seen as a watershed moment for the NHS. An increase in flu cases, more respiratory illness and cold weather have pushed the service up to and, in many instances, beyond its limits this winter.
But what do these pressures look like from the frontline?
We have been running a real-time NHS winter watch with on-the-ground feedback from those leading the health service from the frontline.
Mark Mould, the chief operating officer at Poole Hospital NHS Foundation Trust, was one of the first contributors. He summed up the early pressure on the system, writing that "there hardly seem to be enough hours in the day to fit in all that we do" and adding that winter highlights just "how wonderful" NHS staff are.
Wayne Bartlett-Syree, the director of strategy and sustainability at East of England Ambulance Service, also told us: "Year on year, the NHS is finding it harder to meet the rising tide of demand against a constrained pot of money. We are one flu epidemic or significantly cold winter away from the NHS not being able to cope. The urgent and emergency care system is at times in the equivalent position of trading on the edge."
The difficulties experienced by frontline health and care services this winter should be seen as a watershed moment for the NHS. An increase in flu cases, more respiratory illness and cold weather have pushed the service up to and, in many instances, beyond its limits this winter.
Flu and norovirus have both had a significant impact on demand this winter. Simon Sethi, the chief operating officer at Yeovil Hospital NHS Foundation Trust, told us: "Activity at our emergency department is 14% higher than last year, and we’ve faced the challenge of controlling norovirus outbreaks that are difficult to avoid given its presence in the community."
Trust leaders have also revealed that the patients they are treating this year are older and frailer, with more complex care needs. Katie Slemeck, the chief executive at the Royal Free Hospital in London, told us in early January that this was a challenge for acute and ambulance trusts alike. She also noted there were more "patients admitted with influenza requiring intensive care level support."
Sonia Swart, chief executive of Northampton General Hospital NHS Trust, said patient needs were changing, requiring more long stays in hospital. "Even though we have actually managed to admit fewer emergency patients, those that do come in are older, sicker and frailer, and they stay longer. The number of patients in our beds for over seven days is just about the highest in the country, and has been rising."
At a national level, the number of beds occupied for more than seven days in England hasn’t dipped below 45,000 since Christmas.
The pressures inside A and E departments are having a significant impact on handover times for patients arriving by ambulance. This has been a clear trend throughout our Winter Watch exercise, and in the absence of published OPEL data has been the most remarked-on indicator of how well the system is coping.
Despite substantial progress being made by NHS and local authorities to reduce the number of patients waiting to be discharged in the past six months, it is still a serious problem, adding to pressure on beds. Occupancy remained well above the 85% recommended safe level throughout this winter.
John Child, the service director at Sussex Partnership NHS Foundation Trust, said in mental health services "delayed transfers of care remain an issue, and finding accommodation for people with significant needs relating to dementia and appropriate supported accommodation for those with complex, severe and enduring mental illness continues to be a challenge."
The pressures inside A&E departments are having a significant impact on handover times for patients arriving by ambulance. This has been a clear trend throughout Winter watch, and in the absence of published OPEL data has been the most remarked-on indicator of how well the system is coping. The weekly performance data for the Christmas week was striking. That week, the 137 trusts providing data received 97,706 ambulance arrivals – equivalent to each of the 137 trusts receiving an ambulance every 15 minutes, 24 hours a day. That week, one in six ambulances handovers were delayed by more than 30 minutes.
Performance in A&E has also continued to slip, despite the NHS seeing a record number of patients. In January, performance against the four-hour target slipped to 77.1% for major A&E departments (type 1), the worst performance in seven years. Sonia Swart described one weekend which saw "dreaded queues in corridors, with ambulance crews waiting with their patients. This weekend our four-hour target performance was poor at only 80%, with intense pressure to find a suitable bed for each patient."
Trust leaders have also revealed that the patients they are treating this year are older and frailer, with more complex care needs.
Wayne Bartlett-Syree provided a powerful overview of the pressure faced by his trust this winter, and warned that "it is now commonplace over the winter period for A&E corridors to become full of patients and ambulances to queue outside emergency departments."
How have trusts been working differently this year?
Despite the pressures, trusts are innovating and working collaboratively to overcome winter demand. Simon Sethi explained that "through a focus on ambulatory care, integration with primary care, relentlessly reducing patient waits in hospital, and working with social care” his trust has seen length of stay drop by 10% and has been “achieving the four-hour standard for 12 months."
Katie Slemeck highlighted the level of planning ahead of the winter and the need to reduce elective surgery, so that the trust is supported to focus on emergency admissions. She said: “We have been extensively planning in advance of winter to ensure we can continue to deliver safe care – including significantly reducing our elective programme, and rescheduling outpatient clinics to free up medical and nursing staff to support the increased demand for emergency services.”
Despite the pressures, trusts are innovating and working collaboratively to overcome winter demand.
Meanwhile, Phil Luke, the deputy chief operating officer for Royal Devon and Exeter NHS FT, praised partnership working within his local health and care system. He argued that "the close working with partners in primary care, 111, the ambulance trust, social services, mental health, regulators and leading domiciliary care providers enabled us to refine and strengthen our winter plans."
What next?
Even as the official weekly performance reports come to end, this is certainly not the end of winter pressures for NHS trusts and their staff. In the final couple of weeks of the official winter we saw a sustained cold weather blast, combined with a high number of beds still closed to norovirus symptoms. At the same point last year, trusts started to close escalation beds, but in the penultimate week of February the number of additional beds was up 20%. Ambulance handover delays also appeared to be heading back up again. Trust leaders are telling us that they cannot go on like this indefinitely.
NHS Providers argues trusts must have a say in the forthcoming review of winter by NHS Improvement and NHS England. We need an honest assessment of what the NHS can deliver within its current resources ahead of next time round. The pressures we have seen this winter are a symptom of a fragile system, not the cause of the ongoing challenges. We now need a clear statement of intent and a plan to address – without delay – the long-term funding of health and social care.