News / Bleak midwinter

That winter 2016/17 would be tough for the NHS was not up for debate. As statistics showed the usual summer lull in demand being replaced by activity levels similar to those seen in previous winters, it seemed inevitable that this winter would be particularly difficult. The health service will be grateful for the relatively mild winter so far, though it remains wary of a prolonged cold snap and the ever-present threat of norovirus, but clinicians say December and the first half of January saw unprecedented levels of demand. 

Clinical leaders raised concerns about the quality of care the service can provide and urged the government to re-examine NHS and social care funding. In January, the Royal College of Physicians wrote to the prime minister saying the increase in need was outpacing resources. High demand was paralysing hospitals, preventing their transformation; there were too few qualified staff; and services were ‘struggling or failing to cope’. It called for ‘the reinvigoration of social care services and urgent capital investment in infrastructure’. 

The British Red Cross went one step further, saying the situation in A&E was nothing short of a humanitarian crisis and its staff were helping out in 20 emergency departments.

Its chief executive, Mike Adamson, said: ‘We see people discharged from hospital to
chaotic situations at home, falling and not being found for hours, not being washed because there is no carer to help them. These are people in crisis, and in recent weeks we have started talking about this as a humanitarian crisis. We don’t say this lightly.’

The claim was strongly refuted by both health secretary Jeremy Hunt and the prime minister, Theresa May. She said: ‘We recognise the pressures that the NHS has been under over the winter – this is not unusual. There are always extra pressures for the NHS over the winter period.’

Mrs May agreed to meet House of Commons select committee chairs to discuss their call for all parties to reach a consensus on health and social care funding. However, she is said to be unimpressed by NHS England chief executive Simon Stevens. At a Commons Public Accounts Committee hearing, he appeared to contradict the government’s position that the NHS is getting more than the £8bn it asked for in the Five-year plan.

It’s a highly charged and politicised atmosphere, but what do we know about what’s happening at the frontline? Official figures show pressure is growing. NHS England weekly performance figures for 2-8 January show bed occupancy rates between 93% and 96% – well above the 85% recommended level. 

A recent National Audit Office highlighted growing demand for ambulance services – averaging 5.2% a year since 2011/12. Though it pointed out potential efficiencies, NHS ambulance services said funding had not matched rising demand and it is likely future settlements will be tougher.

The Scottish service turned in a similar performance to last year, with around 88% of patients seen within four hours in the first week of January. However, this was achieved with 3% more attendances. 

In Wales, for all types of A&E unit, the figure was 81% in December 2016 (81.5% a year earlier), though there were fewer attendances than the previous year.

The figures in England particularly prompted stories of an NHS crisis. HFMA policy director Paul Briddock said the NHS had seen this winter’s difficulties coming and had been working hard to limit its impact. 

‘Finance directors have been warning for some time about the impact the current financial situation would have on the quality of services,’ he said. ‘Reports of waiting times and missed targets are the ongoing signs of a decline in quality for patients across the UK.’ 

He added: ‘In July and December last year, the HFMA’s NHS financial temperature check showed that more than one in five finance directors believed the quality of patient services would deteriorate in 2016/17.’ 

And before this, in November 2015, some 43% said they didn’t think the NHS could continue to deliver the current levels of quality within the increased funding currently promised. 

‘This was not media scaremongering but a reality check on the pressures the NHS is under and expected to deliver against.’ 

Some sections of the media, which are perhaps looking for causes of the current problems beyond those already well rehearsed – the ageing population and funding squeeze, particularly in social services – have turned their attention to the role of managers in the planning and delivery of services. Are managers to blame, they ask.

Care Quality Commission chief inspector of hospitals Mike Richards said the NHS as a whole was under tremendous strain. It needed both strong management and additional funding to relieve the pressure.

‘Management is part of the solution, though there’s also the increased activity that ultimately will need more funding. You can’t go on doing more and more with the same funding, so it’s a combination of the two. But we are seeing that those hospitals with strong leadership are doing better in difficult circumstances than others.’

Speaking to Radio 4’s Today programme, he added: ‘I believe the government is going to need to put more money in over time. As and when that does happen, as I hope it will, we need to use it wisely. 

‘I think there have been previous occasions when money has gone into the NHS and it has not been used wisely. That’s when the good leadership, the transformation and greater integration is going to be all-important.

‘Social care is at a tipping point. We do need more funding for social care – there is no doubt about that in my mind – but it is not the whole of the problem. We are seeing increased attendance rates at all ages in hospitals, not just at old age. There are more call-outs for ambulances, more pressure on A&E departments, more admissions. It is a big problem of increased activity, not just about discharge, although that’s important too.’

According to the government, the failure of many GP surgeries to open during normal office hours is adding to the pressure on A&E. 

A National Audit Office report, Improving patient access to general practice, found that 46% of practices in England closed at some point during core hours – between 8am and 6.30pm. Practices are not required to be open during these hours, but must provide essential services to meet their patients’ needs. 

The NAO found that 18% of practices closed at or before 3pm on at least one weekday. However, three-quarters of those practices received additional funding to provide access to out-of-hours care. And patients registered to practices that open for fewer than 45 hours a week attend A&E more often – on average 22 more attendances per 1,000 patients.

Armed with this report, Downing Street suggested that GPs could do more to relieve pressure on A&E by opening during the day and extending opening hours to 8pm, seven days a week. In future, extended hours funding would be linked to GPs offering appointments at the times patients wanted.

Doctors were furious, with the British Medical Association claiming the government was attempting to ‘scapegoat overstretched GP services when the cause of this crisis is that funding is not keeping up with demand’.

NHS Providers called for a wide-ranging review of how winter pressures are managed, including whether the service should revert to dedicated winter funding. It said many trusts believed mainstreaming the funding into the overall NHS budget has led to the loss of winter capacity. The review should also look at the effectiveness of cancelling elective operations and access to primary and social care.

This was always going to be a tough winter for the NHS, but can the service continue to keep muddling through?