As a new strain of Covid-19 triggers yet another surge of hospital admissions, tying up more front line resources, emergency consultants are warning of a grim winter ahead for the NHS.
The most recent NHS England figures show almost 9,000 (8,928) hospital beds occupied by Covid patients on June 30, a sharp increase from the recent lowest level of 3,800 beds at the beginning of June.
And while the success of the vaccination programme means that a much smaller proportion of Covid patients are needing ITU treatment, this increased number of general and acute beds that are not available to treat the normal emergency or elective caseload has run alongside a significant reduction in numbers of acute beds that are occupied.
Bed availability and occupancy figures from Quarter 4 of 2021-22 show there were 3,385 fewer beds occupied than in the equivalent period just before the pandemic (2018-19). So the combination of Covid cases and reduced capacity mean that over 12,000 (almost one in eight) acute beds in England are unavailable for normal activity, and the Covid beds still require nursing cover.
This has led to a drastic drop in performance of emergency services and a continued increase in the waiting list to more than 6.5m.
With this shortage of beds coupled with chronic staff shortages affecting many trusts, and a renewed increase in Covid infections driving up sickness absence, it’s hardly surprising that NHS trusts are unable even to reach pre-pandemic levels of activity, let alone reach NHS England targets to increase beyond them by 10% this year (in the hopes of securing extra funding) in an effort to cut growing waiting lists. It now seems that these targets may have to be abandoned.
The HSJ has published internal data to show that raw elective activity levels from the start of April to mid-June have averaged around 88 per cent of the level in the same period during 2019-20. It quotes Rory Deighton, acute lead for the NHS Confederation, who said:
“We need to be clear that the capacity gap remains stubbornly high…The sooner the government recognises the relationship between elective recovery, social care capacity, and capital investment, the sooner healthcare leaders can start to make further progress on waiting lists.”
The link between reduced capacity and falling performance is especially clear when it comes to A&E and emergency admissions.
NHS England statistics show that although numbers attending A&E have increased since the end of the lockdown and from the lowest levels at the peak of the pandemic, they are in general still below the pre-pandemic level. However delays of over 4 hours in finding beds for emergency admissions have increased, and 12-hour plus delays in finding beds for emergency admissions have increased massively.
In the July-September quarter last year A&E attendances of the most serious Type 1 patients were fractionally (2%) up on the same quarter in 2019, although total attendances were slightly down: but there was a 61% increase in numbers of patients stuck on trolleys waiting over 4 hours for a bed, and a near 8-fold increase in numbers waiting over 12 hours.
In the October-December quarter of 2021 there were 3% FEWER Type 1 patients and 6.5% fewer overall attendances than in the same quarter of 2019, but a 35% increase in 4 hour trolley waits and more than a 7-fold increase in 12 hour waits.
And in January-March this year there was another small drop in A&E attendances compared with the same period in 2019, but a 74% increase in 4-hour trolley waits and a staggering 3,755% increase in 12-hour plus trolley waits.
The reason for this is that the hospitals are increasingly filled with patients who should be discharged to social care, community services or home with appropriate support, but can’t be because the necessary services out of hospital are not in place.
As we reported last month, the new financial year has also seen many, if not all trusts and local commissioners cut the funding that was put in place during the pandemic to help speed the process of discharge and reduce the numbers of patients in hospital for over 21 days.
If patients who should be cared for elsewhere can’t be discharged, this further limits the capacity to treat emergencies and elective patients, and results in queues of ambulances that have been forming with grim regularity outside hospitals across England.
One ambulance crew in Portsmouth recently tweeted a photo of 21 ambulances ahead of them waiting to hand patients over as they arrived with an emergency patient.
Now the Royal College of Emergency Medicine (RCEM) is warning that this situation augurs poorly for the coming winter. They have published a snapshot survey of 60 Emergency Department (ED) leads across the UK (51 of them in England) which found:
- nearly 80% of respondents reported that their hospital had ambulances waiting outside to offload patients every day last week
- seven out of 10 said that their hospital had had to provide care for patients in corridors every day last week
- over one third reported that their longest patient wait in the emergency department in the last week was over two days
Commenting on the findings, President of The Royal College of Emergency Medicine, Dr Katherine Henderson said:
“This is the height of summer and yet we are seeing a state of affairs that we’d be dismayed by even in the depths of winter. One in 10 clinical leads reported that some patients are waiting for more than three days for admission. Corridors are full. Ambulances stuck. Patients suffering. This is not what a recovery is supposed to look like.”
The RCEM has coupled this with a hard hitting critique of NHS England’s 10 point Action Plan for Urgent and Emergency Care Recovery, published last September.
Dr Henderson sums it up: “There has been little action on new metrics. Little increase in same day emergency care provision. Little help for community health teams. Little funding. No timescales. No transparency. No accountability. No improvement. The ‘plan’ has comprehensively failed so far.”
The RCEM notes the particular failure to improve flow through hospitals, without which there can be no improvement in A&E performance:
“The plan failed to address and improve patient flow through hospitals. This winter, average bed occupancy stood at 91.9%, six percentage points higher than the year before. This winter also saw the highest numbers of long stay patients in hospital for seven, 14 and 21 days or more since winter 2017/18. There was a substantial increase in ambulance handover delays. By week 13 of the Winter Sit Reps, delays as a proportion of arrivals were 2.7 times higher than the previous year.”
The RCEM is also scathing on the huge increase in “corridor care”:
“Despite the plan outlining an expectation of no corridor care, in March 2022, NHS England reported the largest monthly increase on record for the number of 12-hour waits from decision to admit, with an increase of more than 6,000 from the 16,404 recorded in the previous month. … Any future UEC strategy must tackle the root causes of crowding by eliminating exit block. High numbers of covid associated admissions is adding to staffing and capacity pressures.”
With the now former Secretary of State having set his face against any increase in NHS resources, despite all this evidence that existing capacity is completely inadequate, and little hope that the new incumbent will be any more responsive to the needs of patients and staff, Dr Henderson concludes:
“As we look ahead to winter, there are no simple solutions to tackle a situation that has deteriorated significantly over the past decade. One thing the government should do is find ways to increase social care staffing as a matter of urgency, as this is where a lot of our problems lie. This will help us to unblock hospitals and get patients moving through the system again.”
Seeing the light on bed numbers?
After decades of efforts by NHS management to cut back numbers of front line beds, there is a hint that NHS England chief executive Amanda Pritchard may finally have seen the light, and recognised that the cuts have gone far too far.
In a speech to the NHS ConfedExpo conference in Liverpool last month, she said that emergency care was facing “winter pressures in the middle of summer.”
She admitted that issues facing social care are not likely to be resolved before winter, but also raised concerns about any further reduction in the number of hospital beds, saying: “The NHS has long had one of the lowest bed bases among comparable health systems, and in many respects this reflects on our efficiency and our drives to deliver better care in the community… [but] we have passed the point at which that efficiency actually becomes inefficient.”
Private sector no help – official
The Lowdown has frequently argued that the private hospital sector, which does not offer any emergency services, and is focused on simple, swift and low risk elective care, is no solution to the NHS problems with delays in emergency admissions and many of more complex elective treatments.
This has been borne out by a recent HSJ report which has found that in eight of the 10 largest specialties by volume the amount of NHS elective work carried out by the private sector in early 2022 was lower than in a comparable period before the pandemic.
This is despite the framework agreement, worth up to £10bn over 4 years, which was signed by NHS England with the private hospitals in order to make it easier for NHS trusts to make use of private beds.
The new HSJ research follows on a similar analysis in December which suggested that despite the rhetoric the NHS sent less elective work to private sector providers in almost all specialties during the first six months of 2021-22 compared to pre-pandemic levels.
The two exceptions, in December and in June were in ophthalmology and dermatology, both of which recorded more activity than pre-pandemic.
The reductions in private caseload identified by the HSJ range from just 2% in oral surgery, 14% in General Surgery, and 16% in Orthopaedics, to more than 20% in Rheumatology, Gynaecology and Urology, 39% in ENT and 47% in Gastroentrology.
The HSJ report appears to struggle to explain the failure of trusts and commissioners to implement a policy that would siphon cash from the NHS and require secondment of NHS staff to make full use of inherently limited private hospitals, whose average size is just 40 beds and many of which are some distance from major NHS hospitals.
The staffing issue does seem to be one practical obstacle: since both the private sector and the NHS can only recruit from the same limited pool of staff, most of whom (other than overseas staff) have been trained by the NHS at taxpayers’ expense, any expansion of NHS work in private beds is likely to lead to further problems staffing NHS wards and operating theatres.
For those of us concerned at the potential increased, long term and costly NHS dependence on the private sector, with a consequent negative impact on equalities and access to NHS care, the failure to transfer the expected amount of work is a positive thing.
But of course evidence that even in the toughest times the NHS does not view the private hospitals as useful “partners” has dismayed the Independent Healthcare Provider Network lobby group. And some of us are quite pleased to see that as well.
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