Key points:
- No significant improvement in winter pressures performance data compared to last year
- Deaths from longer waiting waits are still high
- The target for 5000 extra beds by this winter was not met
- Pressure from each NHS area to stay within budget, but without sufficient funds to achieve it
All last year ministers promised to ensure the NHS was better able to cope this winter than it was last time: but by mid December it was already clear that A&E waiting times were just as bad, if not worse, with an increased number of A&E patients waiting more than 4 hours in September October and November (up 14% on the 2022 equivalent).
Numbers of emergency admissions over the same 3-month period increased by 7% in 2023 compared with 2022, and while there was a 2% reduction in 4 hour-plus trolley waits, the numbers stranded on trolleys for 12 hours or more rose by over 5 percent.
The new figures published as this article is completed show slight increases in emergency admissions, and in 4 hour and 12 hour waits in December, while 2023 as a whole saw an 11% fall in numbers of emergency admissions (to 6.3m) compared with 2022, and a 16% reduction in 4-hour trolley waits (to 1.6m) – but a hefty 13% jump in numbers of 12-hour trolley waits – to almost 420,000.
Dr Adrian Boyle, President of the Royal College of Emergency Medicine (RCEM) said:
“While these data show marginal improvements compared with December 2022, the reality is that there has been little to no improvement in emergency care. … Hospitals remain at unsafe levels of bed occupancy, which presents a significant risk to patient safety. The knock-on effect of ‘exit block’ (whereby we are unable to discharge patients and beds remain occupied for long periods of time) on emergency care is detrimental to patients and their care.
“One year on from the [Urgent and Emergency Care] recovery plan and nearly all of our membership will feel that nothing has changed. They have continued to see full hospitals, corridors crammed with patients, A&Es with ‘elastic walls’ stretched to the limit and queues of ambulances outside. This is their reality.
“12-hour waits were once non-existent and categorically unacceptable, now they are so normalised, with December’s data showing one in nine patients waited 12 hours in A&E.
… “It is a shameful, distressing and deeply saddening situation. The system is failing patients – and in the under-bedded, understaffed, underfunded and under-resourced system – it is existing staff who are stretching, breaking and burning themselves out to ensure patients receive the quality care they deserve.”
Deaths
Analysts LCP have calculated the number of deaths likely to have arisen from the long waiting times in A&E, and estimate these were 415 per week for September-November 2022, and dropped only marginally to 407 additional deaths in the same period 2023, warning:
“this is likely to be an underestimate as no account has been taken of waiting time before the decision to admit and we have not allowed for extra harm arising when delays are more than twelve hours.”
The LCP report concludes that despite far fewer admissions so far in 2023/24 related to Covid-19 and influenza, “A&E departments are not faring any better than last year.” And, since admissions from these respiratory viruses are “now rising sharply”, LCP warns “there is little capacity to handle additional strain.”
Similar concerns of course have been raised by the RCEM, whose calls last Spring for early preparation and increased resources to avert a further disastrous winter period have been largely ignored by the mainstream media – and by politicians from both of the main parties.
Promises
Of course there have been some promises. Almost exactly a year ago, Prime Minister Rishi Sunak promised the NHS would have an extra 5,000 beds available to help the NHS cope in the next winter. The promise was repeated by the latest Health and Social Care Secretary Victoria Atkins on December 3.
Even as she spoke the latest monthly figures available (for November) showed that in fact the ‘Type 1’ hospitals, which handle the most serious A&E cases, had 1,202 FEWER general and acute beds available than the 100,046 when the promise was made. Worse still, this latest total included an extra 2,606 temporary “escalation beds” – leaving the core provision almost 4,000 (3,808) beds less than last January.
And in November more than half of all 165 ‘Type 1’ Trusts had a bed occupancy in excess of 95%, leaving little scope to cope with any increase in demand. The most recent figures show an increase in both core and escalation beds, most notably in January: but even at the highest point of provision so far (January 3) the total number of core acute beds in all trusts was just 98,870, plus 4,000 escalation beds – still short of the 5,000 extra beds.
Funding squeeze
All this has a cost, and the contradictory call from NHS England for trusts and commissioners to rein in spending to avoid hefty financial deficits has come alongside the instruction that trusts must boost the number of “core” general and acute beds to 99,000 by the third week of January.
The situation is worsened by the increase to more than 4,100 beds occupied by Covid patients at the as of January 7, plus an average of 940 beds each day filled with flu patients. On top of this, latest figures show almost one in five (19%) NHS acute beds in England filled with patients who had been there more than three weeks – many of these for lack of adequate social care and community health services to support them if discharged.
This leaves a quarter of front line NHS beds effectively out of action for emergency admissions or for elective operations.
Almost three in ten (29%) beds are filled by patients who had been more than 14 days, and half of all acute beds have patients who have stayed over a week. Indeed figures show the average length of stay, which had been steady or falling has begun increasing, from 5.9 days in 2017 to 6.9 in 2021.
The logjams of ambulances outside too many emergency departments, waiting to hand over patients who have been rushed in under blue lights, are no doubt part of the reason why waiting times for stroke patients to access specialist care have doubled since 2019 according to the Sentinel Stroke National Audit Programme.
Every patient with acute stroke should be given rapid access to a stroke unit within four hours, the key time within which patients can be given clot-busting drugs, or surgical treatments such as thrombectomy. In 2018-19 61 percent of patients were treated within this time frame: by 2022-23 that had fallen to 40% of the 91,000 admitted, putting tens of thousands of stroke patients at risk.
Nonetheless, even though they are surrounded by evidence of the lack of NHS capacity to deal with mounting demand, NHS England appear to have decided to crank up the A&E performance target from the current – as yet unachieved and ever-distant – 76% of patients to be seen and treated transferred or discharged within 4 hours, to an even less credible 80% by March 2025.
The most recent (December) A&E figures (boosted by almost universal 90%-plus performance on the least serious Type 3 patients) have fallen back below 70% in England. Performance on the more demanding Type 1 patients was even worse, averaging 54.7% nationally, with 11 of the 42 Integrated Care Boards achieving less than 50% and two (Lincolnshire 33.8% and Herts and West Essex 37.6%) falling short of 40%.
Exactly what NHS England hopes to achieve by raising a target before they have even met it remains a mystery. It seems more geared to appeasing Tory ministers than encouraging staff.
However ministers seem to have no qualms about disrupting the NHS: the Health Service Journal noted that the regular pre Christmas circular to trusts and commissioning boards from NHS England, setting out the plans and targets for the coming 2024-25 financial year, was held back because of Treasury interference.
The resulting guidance that was sent out carried one categorical message: “systems will need to plan to balance their books in 2024-25,” another grim warning that however tight the finances have been this year, it is set to get even tougher from April.
Mental health
The pressures are not only being felt in acute hospital services: mental health care too is facing a sharp increase in demand without any corresponding increase in resources. The Royal College of Psychiatrists’ manifesto, calling on politicians from all sides to pay more attention to mental health, points out:
“Almost 1.4 million people with suspected mental illness in England are still waiting to start treatment. […]
“The situation in urgent and emergency care is also dire, with adult acute bed occupancy not falling below 95% in England since May 2022. In June 2023, there were 39,137 emergency and urgent referrals to crisis care teams, an increase of 53% compared with June 2022; 10.7% of the emergency and urgent referrals during this time period were for children aged under 18.”
And large numbers of patients are still being shipped across the country, often to privately-run psychiatric hospitals, for lack of local NHS beds or facilities:
“More than 106,000 inappropriate out of area placement days occurred during the second quarter of the 2023/24 financial year, across all ages and bed types.”
Blaming the doctors
Against the background of rising pressure and strained resources, NHS England has tried to paint the most positive picture of the situation with a January 7 press release boasting that “… the overall waiting list fell by more than 95,000 – down to 7.6 million in November from 7.7 million in October.”
Of course this is partly to set the stage for blaming any worsening performance on the junior doctors’ six days of strike action in January – effectively backing up the government’s claim that the doctors have prevented any further progress.
But of course the various strikes over pay began in the second half of 2022, well after the waiting list had topped 7 million – and could have been avoided, as they were in Scotland, by a government that was willing to negotiate rather than seeking to blame others for their own failure to resource the NHS.
The NHS press release does at least have the decency to acknowledge that the reduction in the lists came “thanks to the huge efforts of NHS staff,” which of course includes the consultants and junior doctors who have faced the biggest net loss of real earnings since 2009, and whose disputes have already cost the government and the NHS more to prolong than they would have cost to settle.
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