Comment

21.03.18

Winter from the NHS frontline

Phillippa Hentsch, head of analysis at NHS Providers, and Simon Keen, the organisation’s media officer, speak to a series of trust leaders in order to paint a comprehensive picture of how the NHS dealt with the winter crisis – and what needs to change to ensure 2018 is different.

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 coming to 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.  

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?

NHS Providers, which represents acute, mental health, ambulance and community trusts, has been running a real-time ‘NHS Winter Watch’ with on-the-ground feedback from those leading our health service from the frontline.

Mark Mould, the chief operating officer at Poole Hospital NHS FT, 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.”

Flu and norovirus have both had a significant impact on demand this winter. Simon Sethi, the chief operating officer at Yeovil Hospital NHS FT, 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,” she wrote. “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.

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 FT, 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 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. 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.”

Wayne Bartlett-Syree of East of England Ambulance Service 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.”

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.

FOR MORE INFORMATION

W: www.nhsproviders.org 

Comments

There are no comments. Why not be the first?

Add your comment

national health executive tv

more videos >

latest healthcare news

NHS England commits £30m to join up HR and staff rostering systems

09/09/2020NHS England commits £30m to join up HR and staff rostering systems

As NHS England looks to support new ways of working, it has launched a £30m contract tender for HR and staff rostering systems, seeking sup... more >
Gender equality in NHS leadership requires further progress

09/09/2020Gender equality in NHS leadership requires further progress

New research carried out by the University of Exeter, on behalf of NHS Confederation, has shown that more progress is still needed to achieve gen... more >
NHS Trust set for big savings in shift to digital patient letters

09/09/2020NHS Trust set for big savings in shift to digital patient letters

Up and down the country, NHS trusts are finding new and innovative ways to leverage the power of digital technologies. In Bradford, paper appoint... more >

the scalpel's daily blog

Covid-19 can signal a new deal with the public on health

28/08/2020Covid-19 can signal a new deal with the public on health

Danny Mortimer, Chief Executive, NHS Employers & Deputy Chief Executive, NHS Confederation The common enemy of coronavirus united the public side by side with the NHS in a way that many had not seen in their lifetimes and for others evoked war-time memories. It was an image of defiance personified by the unforgettable NHS fundraising efforts of Captain Sir Tom Moore, resonating in the supportive applause during the we... more >
read more blog posts from 'the scalpel' >

interviews

Matt Hancock says GP recruitment is on the rise to support ‘bedrock of the NHS’

24/10/2019Matt Hancock says GP recruitment is on the rise to support ‘bedrock of the NHS’

Today, speaking at the Royal College of General Practitioners (RCGP) annual conference, Matt Hancock highlighted what he believes to be the three... more >
NHS dreams come true for Teesside domestic

17/09/2019NHS dreams come true for Teesside domestic

Over 20 years ago, a Teesside hospital cleaner put down her mop and took steps towards her midwifery dreams. Lisa Payne has been delivering ... more >
How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

24/10/2018How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

A dedicated national social care service could be a potential solution to surging demand burdening acute health providers over the winter months,... more >
RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

24/10/2018RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

The president of the Royal College of Physicians (RCP) has told NHE that the college’s new headquarters based in Liverpool will become a hu... more >

last word

Haseeb Ahmad: ‘We all have a role to play in getting innovations quicker’

Haseeb Ahmad: ‘We all have a role to play in getting innovations quicker’

Haseeb Ahmad, president of the Association of the British Pharmaceutical Industry (ABPI), sits down with National Health Executive as part of our Last Word Q&A series. Would you talk us th... more > more last word articles >

editor's comment

26/06/2020Adapting and Innovating

Matt Roberts, National Health Executive Editorial Lead. NHE May/June 2020 Edition We’ve been through so much as a health sector and a society in recent months with coronavirus and nothing can take away from the loss and difficulties that we’ve faced but it vital we also don’t disregard the amazing efforts we’v... read more >

health service focus

‘We are the NHS’: NHS England publish newest People Plan

30/07/2020‘We are the NHS’: NHS England publish newest People Plan

NHS England has published its People Plan for... more >
How NHS Property Services adapted to a new way of working

01/07/2020How NHS Property Services adapted to a new way of working

From May/June 2020 edition Trish Stephen... more >