Meteorologists define winter as December to February: the three calendar months when the weather is usually coldest. Ask an astronomer, however, and they’ll say it’s from the winter solstice to the Vernal Equinox: 22 December to 20 March.
Either way, winter is over but NHS performance reporting has only just caught up. This morning, NHS England published statistics on health service performance for February.
Performance dips are expected during winter when the NHS comes under extra pressure, as recently highlighted by QualityWatch. It’s the time of year we all worry more about our elderly nearest and dearest, as the most vulnerable struggle to keep warm and the incidence of heart attack, stroke and respiratory disease all go up when temperatures go down. The financial climate is fairly frosty too, as recently illustrated in our report A perfect storm.
Just how bad was it this past winter?
At first glance, some of the numbers make for pretty ‘chilly’ (excuse the pun) reading, but just how bad was it?
A major – albeit unsurprising – headline is that February 2016 was another difficult month for emergency care. This winter – December 2015 to February 2016 – has seen A&E performance hit the lowest level in those three months (89.1%) since monthly data was first published in 2010.
This is symptomatic of the pressures on the NHS right now. There’s nothing fundamentally unachievable about the A&E waiting time target: 2014/15 was the first year it wasn’t met since 2010/11. From 2005/06 to 2009/10, the health service only missed the target once (by a paltry 0.12% in 2007/08) despite the requirement to see a higher percentage of people within four hours.
One factor behind the drop in reported performance is that more patients are attending A&E – not surprising, our population is both growing and ageing. But while the actual number of patients who were seen within the target time hasn’t gone down, it hasn’t gone up either. Lack of capacity may therefore be a key factor, rather than surges in demand. Even then, about nine in every ten people are still admitted, discharged or transferred within four hours.
More troubling is the substantial increase in patients who needed to be admitted to hospital, but had to wait more than four hours for a bed. There were 34,853 of these ‘trolley waits’ from December 2010 to February 2011, but 134,552 for the same months in 2015/16 – nearly a fourfold increase. An emergency admission to hospital is always stressful for patients and their families, but waiting on a trolley in the controlled chaos of A&E makes for an even more distressing experience.
Higher levels of bed occupancy means more elective activity has to be postponed: extending waiting times and potentially adding to the anxiety of patients needing treatment. The 18 weeks target was technically met in February 2016, but that doesn’t include several trusts that didn’t report data so the true position may be different. Even then, the waiting list has grown to 3.35 million people – a million more than in the late 2000s. Cancer waiting times have mostly held up, but the key 62-day target for referral to treatment remains unmet.
A major cause of delays in getting people in through the hospital front door are delays getting people out the back door, and problems here often involve other health and care providers. The Health Foundation has funded projects in Sheffield, London and Kent, all of which recognise the importance of working across organisational boundaries to improve discharge processes.
Today’s data shows there were more delayed transfers of care (16,551, nearly 2,000 more than last year) and more days lost to delays (470,718, nearly 47,000 more) in December 2015 to February 2016 than in the same period since 2010/11, when the data was first reported. These statistics are incredibly dry, but – as I was recently reminded when someone I knew was trying to leave hospital to die at home – there are real people behind them.
Social care reportedly accounts for a big chunk of this increase. 151,662 days of delays were attributed to social care from December 2015 to February 2016, over 41,000 more than the 110,427 in the same period twelve months before. That’s a big jump, even allowing for a longer, leap year February, and the stats may finally be reflecting the impact of substantial real-terms cuts on local government.
Likewise, the new waiting times stats for mental health – included in the data for the first time, albeit in not entirely reliable ‘experimental’ form – is a welcome indicator of what’s happening outside acute hospitals.
Maintaining quality in massively challenging circumstances
A straight reading of today’s stats is that performance on a number of key measures has continued to deteriorate. We could speculate about whether it would’ve been worse if the weather had been colder, but it’ll take a while to account for other factors like the characteristics of the latest strain of flu.
Ahead of the 2015 general election, the Health Foundation published a set of briefings on quality. Twelve months on, I think our conclusions – which talked about how incredibly hard the NHS had worked to cope with increasing demand and severe fiscal constraints – still stand.
Similar challenges are shared by the health services in Wales, Scotland and Northern Ireland. The plethora of differences in priorities, metrics and targets means performance comparisons are rarely straightforward. But I suspect the picture isn’t drastically different across the UK.
What today’s data can never properly convey – but tends to be more apparent to patients – is the sheer amount of effort being expended by health and care professionals to maintaining quality in massively challenging circumstances. And I suspect even meteorologists and astronomers would agree on that.
Tim is Senior Policy Fellow at the Health Foundation www.twitter.com/TimGardnerTHF