The latest emergency services data make grim reading: and the Royal College of Emergency Medicine is warning things are set to get even worse, after Jeremy Hunt’s autumn statement came up with no extra cash to address the growing capacity gaps in the NHS.
The RCEM (doing work that really should be done by NHS England, NHS Providers and the NHS Confederation, which are supposed to speak up for the organisations they represent) had pressed hard in the run-up to the Autumn Statement for more funding to enable trusts to deliver on the promise last January of 5,000 extra beds (and ‘most of’ a promised 800 more ambulances on the road) this winter. They got nothing.
The commitments to expand capacity were prominently included in NHS England’s Delivery plan for recovering urgent and emergency care services, published with a fanfare in January.
The 5,000 beds promise was even repeated by the latest Health and Social Care Secretary Victoria Atkins on December 3. But despite her warm words the tightening cash straitjacket on trusts and Integrated Care Boards have meant that ministers and health chiefs have not only failed to deliver many of the main commitments, but the situation has actually got worse.
The most recent statistics show that there were 100,046 general and acute beds available in England when the promise to open 5,000 more was made: but by October there were 2,675 FEWER beds, even taking into account 2,224 “escalation” beds.
Rather than learning the lessons of last winter, the NHS is being forced to repeat the same mistakes again. Indeed, as the BBC revealed back in April, far from putting 800 extra ambulances on the road, most of the new vehicles actually ordered by ambulance trusts were routine replacements that had been delayed by previous spending constraints. Just 51 additional ambulances were planned. And they will then be able to join the regular queues of ambulances outside over-crowded hospitals attempting to hand over emergency patients.
The Delivery Plan also promised “Same day emergency care services will be in place across every hospital with a major emergency department, so patients avoid unnecessary overnight stays.” But figures revealed by the HSJ show that around 40 out of 118 trusts that have been delivering ‘same day’ services are delivering a smaller proportion of emergency care in this way than they were a year ago.
There is also a wide variation in the level of same day activity, ranging from 60% of emergency department caseload in Maidstone and Tunbridge Wells to just 12% in London’s University College Hospital. While the England average is around 40% of emergency cases, there is a postcode lottery, with four London trusts (UCLH, North Middlesex, Epsom and St Helier, Croydon) delivering less than 20%, and 14 of the 118 trusts for which there any figures delivering less than 30%.
Several large providers had seen a substantial drop in the proportion of same day activity, including a 29% drop in Cambridge University Hospitals, a 31% drop in East and North Hertfordshire, a 40% drop in Frimley Health, and a 46% drop in Manchester University FT.
The HSJ report does not identify any possible reasons for the reduction, which is clearly not linked to lack of beds: but it seems likely that staff shortages and delays in accessing diagnostic imaging and other test results could explain the failure to progress one of the long list of NHS England priorities.
Staff shortages will not be helped by vicious new immigration regulations restricting the right of workers – even those coming to work in shortage occupations – to bring family members to live with them in Britain. The new £38,700 minimum wage to qualify for family visas means that the new rules cover almost all the main pay bands of nursing staff.
With the revelation that a staggering 93% of the 51,000 nurses recruited in the last four years have come from overseas, these new restrictions are likely to hit nursing as well as recruitment of vital social care staff.
The Delivery Plan in January also promised to “Speed up discharge from hospitals, to help reduce the numbers of beds occupied by patients ready to be discharged.” Sadly here again, as winter sets in, the promise is yet to be delivered.
A new report from the King’s Fund underlines the lack of any coherent structure or system of working to enable NHS and local government bodies to coordinate efforts and resources, despite the rhetoric about “integrated care.” There were real problems in making effective use even where additional sums of money were suddenly announced at short notice:
“Our research with six sites in England found that they welcomed the Adult Social Care Discharge Fund, but had too little advance notice to develop the most effective plans and ensure value for money. The subsequent £250 million hospital discharge fund was announced with even less notice, and overlapped with the plans that had just been developed to spend the first tranche of funding.
“Most sites said that preventing avoidable hospital admissions was a key priority, but because the discharge funds could not be spent on that, they were in effect diverting efforts away from their strategies to reduce hospitalisations. Because the funds had to be spent rapidly, on services that were available at short notice, they were also in tension with sites’ longer-term strategies to build up the home care market over time and reduce use of excess capacity in bed-based care.”
The most recent figures on delayed discharge from hospital show fluctuations in numbers deemed to ‘no longer meet the criteria to remain in hospital’ and in numbers of these patients discharged day by day: but the numbers remaining in a hospital bed (around 12,000 per day), including the numbers who have been there over 3 weeks awaiting support from social care or community health services (around 6,000 per day) have remained largely constant.
The lack of sufficient beds, limiting hospitals’ capacity to treat both emergency and waiting list patients, is obviously a pressure on the most serious (Type 1) cases brought to A&E, with 152,115 patients waiting 12-hours or more from their time of arrival at A&E – this is equal to nearly one in nine (10.7%) patient attendances to major A&Es in October. Worse still, 44,655 people (more than one in twelve of all emergency admissions) having to wait over 12 hours for a bed even after the decision to admit.
But it is also a problem for elective care, with September figures showing 15 trusts delivering less than 50% of treatment within 18 weeks of referral, against a target of 92%, with the worst performance from Milton Keynes, at 38.1%. (The other trusts in this bottom 15 are Countess of Chester; Stockport; Warrington and Halton; Manchester University FT; Liverpool Women’s Hospital; East and North Hertfordshire; West Hertfordshire; James Paget Hospital; North West Anglia; United Lincolnshire Hospitals; University Hospitals Birmingham; University Hospitals Sussex; and York and Scarborough.)
Bad as these figures are, they tell only the story of acute services, and leave out the growing problems and pressures on mental health services, especially since the Covid pandemic. One snapshot of this comes from the revelation that the crisis-ridden Norfolk & Suffolk Foundation Trust has been sending patients as far afield as Newcastle, Bristol and Kent for treatment for lack of sufficient local beds while a key ward was renovated and then reopened with fewer beds for lack of staff.
The Birmingham and Solihull mental health trust has also faced severe problems including the deaths of three patients, and has now been told for a third time by the coroner to increase the numbers of beds.
And with official figures showing 24,000 children left waiting almost two years to be seen by community mental health services, it’s clear the crisis is reaching intolerable levels in these services too.
NHS capacity is inadequate to deal with the most pressing needs of patients, and can only be expanded if there is an injection of additional capital and revenue. It should not be left to the Royal College of Emergency Medicine to make this point to both the current government, and to their likely successors in the Labour Party, who are riding high in the polls, but doubling down on their insistence that all that is needed are “reforms” and that there will be no immediate increase in spending. We can see where the current cash limits are dragging the NHS: sadly it seems another winter will take its toll on patients and hard-pressed staff without ministers or opposition leaders recognising the evidence staring them in the face.
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