As the promises made by Rishi Sunak and his ministers back in January fade further into the past, they gradually reappear … as much smaller and more conditional pledges, before – ministers no doubt hope – being forgotten altogether.
Back at the beginning of the year Sunak unveiled a “plan for emergency care” that promised to deliver “the largest and fastest-ever improvement in emergency waiting times in the NHS’s history”.
Included then was the promise of 800 extra ambulances, increasing the fleet by 10 percent (including 100 specialist vehicles for mental health patients), and 5,000 “sustainable” hospital beds, all to be backed up by a £1 billion fund.
Although the promised increase in bed numbers was just half the 11,000 extra beds which the Royal College of Emergency Medicine has called for to improve both emergency and elective services, Mr Sunak insisted the plans were both ““ambitious and credible,” despite immediate warnings on the urgent need to tackle staff shortages and wider NHS funding problems.
But even these limited promises have proved to be as worthless as the notorious pledge to build 40 new hospitals.
By April the BBC had revealed that far from putting 800 extra ambulances on the road, most of the new vehicles being ordered by ambulance trusts were routine replacements that had been delayed by previous spending constraints. Just 51 additional ambulances were planned. Although the BBC’s Freedom of Information requests drew replies from only eight of the eleven trusts, it is clear that nowhere near 800 extra vehicles will be on the road by March.
The new performance target set in January was to deal with 76% of A&E patients within four hours – way below the 95% national target set and achieved in the 2000s – by March 2024.
This was clearly chosen as a soft target, because total A&E attendance lumps together those with the most serious needs (Type 1) who are most likely to need admission and available beds, with around half as many of the most minor (Type 3) patients, for whom most Trusts and private treatment centres can treat and discharge close to 100% within 4 hours.
But more than half way to March 2024 the September figures are actually worse than they were in January when the big announcements were made.
Then, in the peak of winter pressures, A&E departments were dealing with 72.5% of patients within 4 hours overall and 58% for Type 1 patients. Now the latest (September) national figures show only 71% of all A&E attenders now being seen within 4 hours, while the average for Type 1 patients is also slightly worse, at 57.6% – with one in six of England’s 42 ICBs achieving below 50%, the lowest of which (Lincolnshire) was at just 39.6%.
A look at the latest trust-level data shows an even bigger variation, with 24 trusts dealing with fewer than half their Type 1 patients within 4 hours. In September alone 28 Trusts kept more than 500 patients waiting for a bed on trolleys for over 12 hours, of which 4 trusts each had more than 1,000 such delays in the month.
Urgent care responses services
The January plan also promised to expand urgent care response services (UCR) in the community: but official figures clearly show this still barely exists in several ICB areas.
While the spreadsheet showing the percentage of UCR referrals that achieved the 2-hour standard in each ICB and each local provider seems impressive (with most scores ranging from 80-100%), cross-checking these with the actual numbers of calls reveals that both of the ICBs claiming 100% performance each handled just FIVE calls in August (Cornwall and Shropshire Telford & Wrekin and).
Sixteen of the 42 ICBs– almost 40% – (3 Eastern Region, 6 Midlands, 5 South West, 1 each in South East and London) handled fewer than 1,000 UCR calls in the month, with two more (Devon and Lincolnshire) handling fewer than 200.
Only five ICBs (West Yorkshire, Coventry & Warwickshire, NW london, Sussex and North East and North Cumbria) responded to more than 7,000 UCR calls in the month. There seems a long way to go before these services make a measurable impact on emergency services across many parts of England.
Elective services, too, have been going downhill rather than improving. When Rishi Sunak back in January made his pledge to reduce the size of the waiting list by March 2024, the waiting list sat at 7.2 million, it is now closer to 7.75 million … and increasing by around 100,000 per month.
So what has happened on the promise of opening more beds? It’s fair to say it was at best ambiguous in January, with Department of Health statements soon afterwards muddying the waters with talk of setting up 3,000 “hospital at home” beds before this coming winter.
Of course these are not beds that can be counted as NHS capacity, since they amount simply to setting up community-based teams of staff to visit and support patients at home, rather than treat them in hospital. When the patient eventually recovers, dies, or, as the allotted maximum time is reached, is re-assessed to need continuing care in a care home or hospice, the “bed” is no longer available. It is a notion rather than an asset.
Given the ongoing staff shortages, with over 43,000 nursing posts vacant in England at the last count, there are major doubts over how many of these services can be maintained – and for how long for each patient.
The same goes for the similar notion of ‘virtual beds’, the concept of which was described as “transformational” by Rishi Sunak. These are being repeatedly promised and discussed as if they are a new NHS resource: but again the bed belongs to the patient, who would be monitored at home using new technology – which needs to be watched over by a team, and backed up by the ability to mobilise a swift response to any worsening of the patients’ condition.
In North West London, one of the areas most committed to urgent care response, the ICB has opted to run down rather than increase the number of virtual beds, cutting “from 1,100 to 300-400 beds, based on the expected requirement for these beds and current occupancy.” Here too, it is inappropriate to discuss the resource as beds rather than the team of staff and the equipment required to enable care to be delivered in a patient’s home.
What, then of the 5,000 extra “sustainable” beds promised so noisily in January?
A DHSC press release in mid-August shifted the goalposts in several respects. It announced just £250m of the promised £1 billion funding was being handed over, apparently to add just 900 extra beds. This was billed as “part of plans” to deliver “an additional 5,000 additional permanent beds,” which the release implausibly claimed the NHS was “on track to deliver by winter.”
Rishi Sunak had drastically downsized his January claims to argue “These 900 new beds will mean more people can be treated quickly ….”
Sadly for patients – and for Mr Sunak if he really cared at all about telling the truth – is that NHS figures in September show bed numbers in the Type 1 hospitals that admit emergency patients were 3,258 lower than they were in January. So big has been the reduction that even opening the promised 900 “extra” beds now would still leave 2,358 fewer beds than there were at the beginning of the year.
Nursing unions and the BMA were also quick to point out that given staffing shortages – exacerbated by the government’s stubborn refusal to negotiate a realistic settlement with the BMA, and NHS England’s attempts to block deficit-ridden trusts and ICBs from recruiting additional staff – beds without staff are “useless”.
However there is also no guarantee the extra cash (for what it’s worth, given the widespread problems with inflation) will be allocated where it is needed most.
The DHSC press release in August revealed that just 30 NHS organisations across England get a share of the £250m, with hand-outs ranging from just £2.1m in Croydon to £24m for Leicester Hospitals.
This leaves 75% of England’s 121 Type 1 trusts with no additional funding to prepare for winter.
Extra lumps of cash were handed out apparently randomly, although the losers were the North West and North East regions who shared just under £40m between them, and the South West which received an even more miserly £13m. The West Midlands did best, receiving £60m.
Nor will all of the extra money be used for beds, according to the DHSC release. Several trusts will “develop or expand urgent treatment centres to treat patients [with the least serious needs] more quickly,” while others will also use the funding “to develop or expand same day emergency care services.” The press release adds that some of the money will be spent on other things, too, such as to “improve assessment spaces and cubicles in A&E.”
And there is another problem which questions the viability of simply expanding hospital bed numbers without fixing the massive problem of inadequate and dysfunctional social care.
Rishi Sunak in August claimed that the 900 extra beds would result in “speeding up flow through hospitals and reducing frustratingly long waits for treatment.” But to flow through patients must be able to flow out: the other blockage is at the discharge end of the process.
The latest figures show that while more beds may for a while get more patients in to hospital faster, they will soon fill up – for lack of proper resources to support patients after they are discharged.
In September a staggering 50% of beds were filled with patients who had been in hospital for over a week: almost 30% held patients who had been there more than 14 days, and one in five beds held patients marooned for over 3 weeks.
In June the Health Foundation drew attention to the increase in average length of stay, after decades in which it had been steadily falling. Without attending to the social care system, with its chronic staff shortages, and to community health and GP services that are also key to supporting patients discharged from hospital care, there is no way to enable the hospitals to work efficiently.
And without investment in increased preventive public health measures and early interventions – and systematic government-led policy changes to reduce poverty, and narrow rather than widen health inequalities, there is little hope of substantially reducing the numbers of patients needing hospital care.
Promises are easily made, and apparently easily broken: but fixing the health and care crisis created by 13 brutal years of austerity requires determined action to increase spending on services and resources – whichever government eventually takes on the task.
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