Very real risks to resilience

Source: NHE Jan/Feb 17

Analysis has revealed that some areas of care are being sustained or even improved despite intense pressures, but Robert Reed, research analyst at the Nuffield Trust, explains that the NHS in England is facing serious challenges in maintaining standards of care.

The New Year has seen numerous reports of the NHS under immense strain this winter. There have been warnings from the head of the British Red Cross of a ‘humanitarian crisis’ in the NHS as hospitals and ambulance services struggle to cope with rising demand. Leaked figures suggested that over one-fifth of patients waited longer than four hours at A&E in January. And our own analysis found that a third of hospital trusts declared ‘black alerts’ in December. 

There is no doubt that the NHS is grabbing headlines this winter. But what does the data actually tell us about care quality and the resilience of the health service? 

The Nuffield Trust and the Health Foundation have been monitoring the quality of health and social care in England for a number of years via our QualityWatch programme. QualityWatch takes a long view of quality in health, using over 300 quality indicators and in-depth research to explore the state of care quality in England.  

Our most recent QualityWatch annual statement found that, while some areas of care were being sustained or even improved (such as patient experience, ambulance call handling and stroke care) despite intense pressures, the NHS in England is facing serious challenges in maintaining standards of care. We argued that the deterioration in waiting times we see now did not begin until some years into the current decade of austerity, suggesting that the NHS managed to mitigate financial pressures – but only up to a point. 

Our analysis highlighted three areas of particular concern: 

First, the number of patients on the waiting list for consultant-led treatment has increased substantially. In recent years the number of patients waiting for treatment has grown, and stood at just below 3.9 million in November 2016. 

Second, response times to the most urgent life-threatening ambulance calls continue to deteriorate. Most recently, in November, just 68% of Red 1 calls (respiratory and cardiac arrest) and 63% of Red 2 calls (all other life-threatening emergencies) were attended to within the eight minute standard. 

Third, there has been a slowdown in the progress towards eradicating healthcare-associated infections (HCAIs) and an increase in the number and rate of less well-monitored infections like E. coli. 

Increases in the number of patients on waiting lists raise concerns over health outcomes for patients. A slowing in the progress against HCAIs is made more concerning in the context of high bed occupancy rates, particularly during winter. Last winter for example, on 26 January, no fewer than seven extra hospitals’ worth of beds had to be opened just to meet demand.

If ignored, these three problem areas may worsen, especially at a time when financial stringency is increasing, in spite of ever-growing demand for services. The NHS and social care enter 2017 amid the tightest funding settlement for decades. Workforce shortages and pay freezes are continuing across the NHS and the recent Autumn Statement offered no relief from austerity. 

One key element of resilience is the ability to acknowledge problems and address them before they grow. Solutions do exist to these problems – investing in staff across the whole health service, improving systems and processes within hospitals and ensuring the right support exists in the community. But these all take time and money – both of which are in short supply. 

A key conclusion from our QualityWatch report was that the hard work and goodwill of NHS staff may have prevented certain areas of performance from declining even earlier. This same hard work and goodwill means that high-quality care is still being delivered at many levels in many services across the NHS, despite the intense pressures under which it is operating. But the big question for the future is how long this can be maintained.

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