Health Service Focus

We need a new approach to winter pressures

Winter is traditionally the busiest time for the NHS. This winter has – in many respects – been the worst for many years.  Demand has climbed to record levels in the midst of the longest and deepest financial squeeze in the history of the health service, writes Deborah Gulliver, senior research analyst at NHS Providers.

Recent media coverage of what has been called the ‘NHS winter crisis’ has drawn on daily winter performance data for 152 hospital trusts, published weekly by NHS England. The publication this Friday of the final data for the peak winter months (December to February) means we can now track those winter pressures and gauge their impact on the NHS.

What does the data show?

Between December 2016 and February 2017:

• On average each of the trusts admitted at least 80 emergency patients per day
• Compared to last year, the number of times patients were diverted to other A & E departments due to a lack of capacity almost doubled
• Bed occupancy rates remained well above the recommended safe level of 85% for all weeks, peaking at 96%
• In January, the number of escalation beds (opened temporarily to create extra capacity) reached the equivalent of opening an additional eight hospitals 

What does this tell us?

A&E is often seen as the touchstone for the whole health system. Other data reveal similar pressures affecting community and mental health trusts, ambulance services, GPs and social care.

These pressures have contributed to the worst figures on record against the A&E four-hour waiting target; with the latest monthly figures from NHS England (December 2016) showing performance of 79.3% for major (type 1) departments. The target of 95% is far beyond reach. Delayed transfers of care remain at record levels as trusts struggle to find suitable support for patients who are medically fit to leave hospital. And the percentage of the most urgent ambulance calls responded to within eight minutes reached its lowest level this year, 66.4% for Red 1 and 58.8% for Red 2, well below the 75% target.

The “OPEL”, or operational pressures, figures reflect trusts’ judgements about the pressures they face. They range from level one, where all is well, to level four, requiring “decisive action” to ensure patient safety. As they are a new measure, and their definition was changed during the winter, direct week-to-week comparisons are difficult. However, the rise in the number of level three and four alerts from mid-January indicates a service struggling to cope.   

Despite this, most trusts have managed to “keep their heads above water”. The reality is that the we know we are neither facing a “humanitarian crisis” nor “coping well”.

It is clear the NHS has been “running hot” for an extended period. Although trusts are working hard to keep pace with demand, they are operating at capacity levels beyond those which other international health systems would regard as acceptable. 

As pressure continues to grow, the likelihood of more trusts reaching and moving beyond breaking point increases. 

For patients these difficulties are distressing and potentially dangerous. They are also demotivating and demoralising for the clinical workforce, who sometimes feel they are struggling against all odds to provide the best possible care. It is thanks to the extraordinary efforts of frontline staff that we have made it through this winter period without a full-blown crisis. However, trusts are telling us that it was a close-run thing. It is evident that we need a better approach.

Review of winter pressures

NHS Providers has called for a formal review of how the NHS has managed winter pressures, led by NHS England and NHS Improvement, with direct input from NHS trusts which have borne the brunt of rising demand. The review should also include the views of other expert bodies, and the results should be made public so patients and service users can be confident that the health service is learning from this year’s experience. 

It needs to be wide ranging. In particular, it should look at the ring-fencing of winter funding and the impact of cancelling elective operations. It should also explore concerns over access to GPs, and how social care supports the NHS. 

The health secretary has acknowledged that the NHS is facing “completely unacceptable” problems. He should now accept that we can not approach next winter without learning from the events of recent weeks.

The relentless year-on-year rise in demand means winter conditions remain in place year round for the NHS. So, the resilience of trusts to deal with unexpected spikes in pressure, such as flu outbreaks and norovirus, is compromised. We can not afford to ride our luck indefinitely.       

NHS Providers has published a full breakdown of the winter performance data for December 2016 to February 2017 in an interactive briefing. 

(Image: c. Rui Vieira and PA)

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