Comment

Winter in the dark: the value of robust data

Ruth Thorlby, assistant director of policy at the Health Foundation, argues that a lack of data across social, primary and community care compared to the hospital sector means planning for winter will always be incomplete.

Not even halfway gone, this winter has already whipped up a vicious political storm over the NHS. Official figures are released each week and are making for increasingly grim reading, supplemented by a barrage of graphic first-hand accounts from patients and staff about the conditions inside hospitals.

Rows have erupted between the government and those close to the service about whether this is or isn’t a crisis, whether the preparation has been better than ever before or hopelessly inadequate, and whether this is all about flu or chronic underfunding.

The first detailed plans were published in August by NHS England and set out what was to be done across the health and care system to minimise the impact of winter. These plans encompassed four phases of patients’ contacts with the NHS: upstream measures to keep people well in the community, prompt access to emergency care when needed, maximising capacity for patients in hospitals, and making sure people can be discharged quickly after a stay in hospital.

Keeping people well in the community depends on capacity in primary care, and strategies included expanding weekend and evening access to GPs and providing financial help with professional indemnity (insurance) to allow more GPs to take on shifts in out-of-hours and urgent care centres. It is not clear how successful this will be: the GP workforce has dropped by 2.3% over the past two years, and the evidence that extended GP access reduces demand on emergency departments is limited.

A rise in illness

For patients needing urgent advice, NHS England planned to increase the proportion of clinicians handling calls to 111, with the aim of reducing the number of patients triaged to ambulances or advised to attend A&E. The NHS 111 data for December 2017 paints a picture of huge demand. More patients called NHS 111 during that month than ever before: an average of 54,000 per day and a 13% increase from December 2016. Nearly 40% of calls were handled by a clinician, and although the percentage of referrals to ambulances or A&E remained similar to a year ago, the numbers are higher because of the overall increased demand. In December, nearly 162,000 ambulances were called and 93,000 people were advised to attend A&E after calling NHS 111.

The NHS 111 data strongly suggests a rise in rates of illness, an impression borne out by the surveillance data for flu, released by Public Health England. In the first week of this year, the weekly consultation rate for ‘flu like’ illnesses in general practice in England was double the rate from before Christmas, with similar steep rises in admissions to hospital and ICU departments for confirmed cases of flu.

This all points to a surge in demand for hospital care, but flu is only part of the story. The weekly data released by NHS England since November show a steady rise in the numbers of people admitted to hospital as an emergency: in December, there were 520,163 emergency admissions, compared to 497,915 in December 2016.

It is this steady increase in the proportion of sicker patients coming into hospital that has put intense pressure on A&E departments and on hospital beds. Four out of five hospitals reported bed occupancy of over 92% in the first week of January, despite the opening of ‘escalation beds’ across the country and the recommendation by NHS England that hospitals should postpone non-urgent procedures to release staff to care for the sickest patients.

Inevitably, this rise in demand at the front door has made achieving the four-hour A&E target even more unlikely. Performance against the target was the worst last month since records began, and the cancellation of elective procedures will likely worsen the performance against the 18-week referral to treatment target.

Tackling delayed discharges

The sheer intensity of the pressure on the front door of hospitals revealed by the data has obscured progress in one important dimension: delayed discharges. Earlier in 2017, work began to substantially reduce delays ahead of winter and free up 2,000-3,000 hospital beds. This was backed by an extra £1bn of funding for local authority social care services, announced in the Spring Budget that year.

This effort appears to have had some impact. Between April and November 2017, 1.4 million days were lost to delays – around 87,000 fewer than the 1.5 million days in the same period in 2016-17. In November 2017, the latest month for which data has been published, there were 1,271 fewer delays per day than in the same month in 2016.

But despite the progress, it is some way short of the ambitious target set out in the government’s mandate to NHS England to reduce the percentage of hospital bed days occupied by delayed patients to 3.5% (around 4,000 delays per day) by the end of September 2017. In November, the number of delays per day remained stubbornly over 5,000 (5,169).

The state of social care

This brief scan of the data behind the winter headlines is striking because of what can and cannot be seen easily. There is an abundance of hospital data. On a daily basis, the number of beds open (including ICU for adults and children) is visible; so too the number of people waiting in ambulances and in A&E departments. This is not, however, the case for social care.

Skills for Care estimates that about 1.4 million people work in the social care sector in England – substantially larger than the NHS workforce. The CQC estimates there were a total of 459,670 nursing and residential care beds in 2017. This dwarfs the hospital sector, which has about 142,000 beds, including mental health and learning disability beds. But at a national level we remain totally in the dark about the availability of beds in social care, and about the state of the care workforce.

There’s a similar lack of data about the other huge sector in the system, primary and community care. We have no idea about the number of people attending GPs on a daily basis, or visits by district nurses and other vital community staff.

Some local health economies have a better grasp of demand and capacity across all sectors of their health and care system. But at a national level, planning for winter will always be incomplete while the data and resources are skewed so heavily to the hospital sector.

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