Why is there a winter crisis?
The winter of 2015/2016 was very mild, one of the mildest on record, with no major long cold spells. Such benign weather generally means that the NHS is under less pressure. So it is extremely concerning that despite the mild climate, the NHS's performance figures for both January, February and March 2016 were the worst on record.
This is the third winter in a row that the NHS has been in crisis and despite analysis of what happened in previous years, lessons do not appear to have been learnt.
Targets missed again and again
The NHS has national minimum waiting time targets for numerous situations, including A&E, elective surgery and cancer diagnosis and treatment. This makes it relatively easy to track how the NHS is performing in these areas.
The statistic that always makes the headlines is the wait in A&E: there is a national target that 95% of people should wait less than four hours in A&E. The latest performance data for January and February 2016 showed that only 83% of patients who attended A&E were seen within four hours in January and 81.6% in February, way below the 95% target.
Delays to treatment were not confined to A&E - the largest number of people since records began had to wait more than the maximum of 18 weeks for planned care in hospital and the NHS also missed its targets in many other areas, including cancer referral times.
The strain showed early
The pressure on the NHS was evident way before the January and February 2016 figures: NHS England released its first set of situation reports data on 11 December 2015 detailing several performance measures for the NHS in the first week of December.
Already 12 hospital trusts did not have a single bed available from 4-6 December, and another 30 had fewer than 10 beds free for patients. A&E departments were struggling, including County Durham and Darlington NHS foundation trust, which had to shut its A&E 11 times in the first weekend of December and King’s College hospital, a major teaching hospital and centre of excellence in south London, which had to shut its A&E three times in the first weekend in December and also on Tuesday 1 December.
Third year in a row
Judging from the performance figures for the 2015/2016 winter, the NHS was in crisis for a third winter in a row. In the two previous winters, there was extra money to throw at the problem - in winter 2013/2014 the NHS received £250 million and in 2014/2015 it received £700 million - however in 2015/2016 there was no extra money.
As well as no extra money the NHS is struggling under mountains of debt; the NHS is on course for an annual deficit of at least £2.8 billion and regulators have described the situation as the worst financial crisis in a generation.
Analysis of the crisis
In an effort to determine why the crisis happened in the winter of 2014/2015 despite the £700 million cash injection, The Nuffield Trust analysed the crisis – what was the money spent on and why did it not help the situation? In early December 2015, The Nuffield Trust released its report; The A&E Winter Crisis: lessons from last year .
It might come as a surprise to many people used to media stories over the inappropriate use of A&E, but the Nuffield Trust’s analysis shows that the problems in winter are not caused by more people turning up at A&E, in fact, fewer attend in cold weather. However of those that do attend A&E admission rates are relatively high and there is an increase in people with breathing problems who need to spend longer in hospital.
The underlying cause of the crisis is that bed occupancy is much too high, often around 92%, so there is no flexibility in the system and it collapses quickly as more patients are admitted. The ideal rate for bed occupancy is 85% as this allows flexibility in the system so a spike in admissions is no problem.
Most notable in the analysis is that a small number (just under 4%) of patients are not discharged from hospital when they should be and this has a major knock-on effect through the hospital.
The report concludes the following:
- Winter crises in A&E are caused by blockages in moving patients through hospital beds and sending them home – not by more people turning up.
- These blockages happen because NHS wards are fuller than they should be. The Health Service is 14,000 beds short of a level that would provide reliable capacity.
- 41% of extra winter funding last year was spent on simply adding additional beds and staff. But there is nowhere near enough funding to actually close the gap in number of beds.
- Instead, money and focus should be used more strategically. 3.6% of patients account for 37% of time in NHS beds. Finding ways to safely treat these people outside hospital should be a major priority.
The Nuffield Trust analysed how the £700 million provided in winter 2014/2015 was spent - £254 million (41%) was spent on extra beds and staff; £74 million (12%) of money spent on minimising delayed discharges; and seven day working absorbed £61 million.
The report noted that spending money at trying to increase capacity is just not feasible as nowhere near the number of beds actually needed (14,000) can be created to avert the crisis this year due to both time and lack of funds. Instead the report concludes that the target for spending should be the set of patients who really do not need to be in hospital.
These patients would be better cared for either in their own homes, special housing or nursing homes, where they generally do better if supported by community services. The Nuffield Trust concludes that “reducing length of stay among this group could make a disproportionate impact in controlling how full wards get. Looking carefully at how they are treated could also help to avoid the hold-ups in moving people around that tend to form the triggers for blockages and crises.”
Good social care the key
So according to the Nuffield Trust's report, adequate and good social care is the key to avoiding a winter crisis in the NHS as it allows patients to be discharged thus freeing up beds. Taking this one step further, it is also true that good social care is the key to controlling the number of vulnerable patients that turn up at A&E and need to be hospitalised.
Social care starved of funds
Although it is clear that social care plays a major role in averting a winter crisis, the government seems determined to starve this sector of funding.
In early December soon after the spending review a letter signed by a number of organisations including the Association of Directors of Adult Social Services and the NHS Confederation was sent to chancellor George Osborne, health secretary Jeremy Hunt and local government secretary Greg Clarke, called for “concerted action” from the government to avoid the financial crisis currently affecting social care.
The group noted that the settlement delivered in last month’s spending review is “not sufficient”, “not targeted at the right geographies” and “will not come soon enough to resolve the care funding crisis”.
Just a few days after the Nuffield Trust reported its findings, a training scheme designed to create a career pathway for care workers and address the shortage of nurses in the care home sector was axed. The £178,000 scheme would have developed the role of care practitioner, training care assistants to take on some of the roles of nurses.
The start-up funding for the scheme had been promised by the UK Commission for Employment and Skills (UKCES), a government quango, under a £1 million programme to find “workplace solutions to the gender pay and opportunity pay gap”. But the promise was withdrawn after the spending review.
On the 12th December three days after the Nuffield Trust report, The International Longevity Centre reported that “despite a pledge from George Osborne that social care could expect a cash boost through local authorities raising council tax, there would not be enough money to meet the needs of a growing older population.”
The ILC-UK Centre for Later Life Funding supported by Age UK conducted a detailed analysis of the social care funding measures outlined in the Spending Review.
The report ‘The End of Formal Adult Social Care?’ points out that even if the spending review announcements bring £3.5 billion into adult social care, a scenario they describe as “highly unlikely”, this will still “only mean that spending on care returns to 2015 levels by the end of the Parliament. This level of funding would imply an overall fall in expenditure on care as a proportion of GDP putting us firmly towards the bottom end of the OECD league table.”
Lessons from previous years ignored
The most logical and obvious method to avert a crisis in our hospitals in winter, funding the adult social care system, is being ignored and starved of funding.
The NHS is now in a no win situation, no money and no help from other services, it’s on its own and it was no surprise then that the performance figures from January, February and March 2016 were the worst ever recorded.
The crisis created by the Government, will then be used as a reason by the Government to dismantle the NHS even more, privatising the system.