As winter approaches, with the days growing shorter, the warnings from the Royal College of Emergency Medicine are growing more frequent and anxious.

Responding to the Labour government’s first Budget Dr Ian Higginson, Vice President of the Royal College of Emergency Medicine, said:

“We commend the government’s ambition to start rebuilding the NHS which has been clear from the Darzi Review, the national public consultation, and willingness to invest in health and social care in today’s budget.

“The commitment to increase the number of beds in the system is welcome, although we need to see the detail and time frames as we know at least 10,000 beds are needed now to improve patient safety and reduce long waits in our departments.  We’ve also got to remember that buildings don’t just appear, whilst equipment and beds need staff.

“Additionally, it must be ensured that while the health service is bolstered, social care is not left behind. We cannot fix one without fixing the other.

“While today’s budget offers a range of investment plans, from our perspective the elephant in the room is that there was absolutely nothing aimed at mitigating the looming winter crisis we are facing in our EDs, and no discernible direction of travel for what will happen in future winters.”

Dr Higginson added:

“As you read this, vulnerable patients will be stranded on trolleys in corridors in A&Es across the country. This will only be exacerbated over the next few months. “Long waits are not only degrading for people who are seeking emergency care, they are dangerous. We know they are associated with excess deaths. They are also one of the main reasons skilled staff are choosing to leave emergency medicine, and the NHS.

“The health secretary acknowledged this week that people will continue to receive care in corridors this winter, and that there would continue to be deaths associated with long stays in EDs. To seemingly just accept this is shocking and deeply disheartening for clinicians whose main aim is to offer patients timely, effective and dignified care.  We cannot do the same.”

It’s already too late to begin serious plans to avert yet another winter crisis in which blue light ambulances queue outside overcrowded A&E departments, and the most seriously ill emergency patients wait hours on end on trolleys before finally being admitted to a bed.

A brief snapshot of bed occupancy levels in September shows the RCEM is right to be concerned. Almost a quarter of acute trusts (43 out of 134) and nine of the 42 whole Integrated Care Systems already had bed occupancy levels on or above 95%, with adult bed occupancy levels even higher. The maximum safe level to allow a mix of emergency and elective work to continue is 85%

One of the problems created by increasing bed occupancy is delays in discharging patients. Despite repeated efforts by NHS England to force trusts to find ways to get patients discharged faster this remains a stubborn problem, centred on the lack of adequate community health care, primary care and social care resources to support patients out of hospital.

In September just one of the 42 ICBs (Shropshire Telford and Wrekin) had fewer than 20 percent of acute beds tied up with patients who had been there for over 14 days.

But this understates the problem: time series statistics show that at an England-wide level the number of beds filled with 14-day plus patients has remained above 29% for the last 12 months, and numbers of 3-week plus patients have only dropped below 19% in 3 months since 2021, the most recent being last December. The only escape from this requires additional investment in suitable services – an area which was not mentioned in Rachel Reeves’ budget.

It is this limit on the use of its acute capacity that delays the treatment of emergency patients; but it also hampers efforts in many hospitals to reduce waiting lists, which have remained above 7.6 million.

With bed capacity under constant strain, the only hope of improved winter performance would be if there were any sign of reduced pressure on A&E: but again time series statistics show that numbers have remained consistently high since May 2021, after the peak of the Covid pandemic was over.

None of the talk from ministers and NHS chiefs about ‘preventive care’ or efforts to divert patients to other forms of care have been backed by any serious resources, and they have had predictably little or no impact. Nor could they, with levels of the most serious Type 1 cases, and emergency admissions, almost unchanged from year to year.

The mismatch between demand and bed availability explains the substantial 18% increase in 12-hour plus trolley waits in the 12 months to this September compared with the same period last year, and the astonishing increase from just 458 12 hour waits in September 2019 to 38,880 five years later.

But what of the promised extra beds to help tackle winter crises? In January 2023 then PM Rishi Sunak promised “an extra 5,000 beds” would open by the next winter. As he spoke there were 100,046 general and acute beds available; but at no point has the total been brought back up to 105,000: the highest was 103,408 in February 2024.

NHS England called on Trusts to ensure a total of 99,000 ‘core’ beds were available to tackle a flu outbreak in January and February, but since June the total of core beds has dipped back down below 99,000, and the latest total of acute beds (September) was just 100,640, boosted by over 2,000 “escalation beds.”

Of course the beds alone are not enough to tackle the likely surge in demand for emergency care: the correct mix of staff needs to be in place: but with financial pressure leading almost every ICB and Trust to seek ways to cut spending by shedding staff, it remains to be seen whether the winter pressures will also bring a turn back to employing more agency and bank staff to plug the gaps.

After the budget’s apparent generosity to the NHS – even if it was largely smoke and mirrors – we can expect the Chancellor and PM (as well as millions of patients) to be hoping to see a positive change in waiting times and waiting lists.

But after 14 years of under-funding having depleted resources to such an extent there must be long odds against the NHS managing to deliver a winter miracle.

 

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