The resilience of those working in the NHS and social care is being tested to its limits this winter. The late arrival of cold temperatures has postponed spring and any early end to the pressure on services. There was more planning ahead of winter this year than in previous years, but the weekly situation reports from NHS England have made for grim reading. Despite the postponement of non-urgent operations, the opening of escalation beds, and a big push to reduce the numbers of delayed transfers, hospital bed occupancy has remained high (averaging 95% last week), as have the numbers of patients being delayed in ambulances because emergency departments are so full (420 patients waited more than an hour each day last week).
There is a striking amount of consensus about the causes of this: demand for services has outstripped funding growth, and the data from hospitals is symptomatic of pressure both inside the acute sector but also in primary and social care. To underline this, NHS Improvement’s latest quarterly performance report included data on staff shortages for the first time and states that there are around 100,000 vacancies, including 35,000 unfilled posts in nursing. The report covers the period up to 31 December, and the costs of mobilising enough staff to meet winter-led demand for emergency hospital care are all too obvious: although spending on agency staff has been reduced, trusts spent £664 million more than planned on bank staff to fill rota gaps. Trusts also overspent by £292 million on buying alternative care from the private sector, another reflection of the capacity constraints within the NHS.
Shortages of staff are not evenly distributed, geographically or by specialty. Although a lot of media attention has been paid to the efforts to reduce delays in getting predominantly older people out of hospital, shortages of staff have been affecting services for other age groups too. The 0-15 years age group makes up about the same proportion of the population (18%) as the over 65s, but there has been less coverage of the impact of winter on children’s use of health services. As Dr Susannah Pye, paediatrician and clinical fellow at the Health Foundation explains, shortages of staff will have been keenly felt by those caring for children this winter in both general practice and hospitals.
The release of weekly data by NHS England over the winter has served an important function in terms of transparency: no one can be in any doubt about the severity of the pressure on the NHS. But the data are partial: it is a view through a very narrow keyhole. As Dr Rebecca Fisher reflects, the public might be surprised to learn that on a weekly or even monthly basis, the senior leadership of the NHS remains in the dark about the pressures on general practice – where the vast bulk of contacts between patients and the NHS takes place, or indeed social care capacity – which has a workforce even larger than the 1.1 million NHS staff base in England.
A more comprehensive data set would certainly allow policymakers to have a more holistic overview of demand and capacity across the health and social care system. But the collection of data comes with costs, and one of the most important attributes that data need to have to be useful for improving the quality and efficiency of care is the ability to be linked, so that patient care can be tracked across services.
This winter, for example, one service which has seen a planned increase in capacity is NHS 111, the telephone advice line for urgent care. In December 2017, NHS 111 handled its highest ever number of calls, over 54,000 per day. This winter it has also seen the highest proportion of calls handled by a clinician – nearly 40%. The logic behind this increase, according to NHS England’s board paper in September 2017, was that increased clinical input could reduce ‘dispositions to A&E departments and ambulance services.’ Careful analysis of linked data, which tracks what happened to patients after calling NHS 111, is needed to build the evidence base. The Health Foundation’s data analytics team has conducted such an analysis, albeit for a segment of the patient population – in this case children – in a subset of clinical commissioning groups in London. As Adam Steventon, our director of data analytics explains, the research shows the relationship between increased clinical input and reductions in pressure on emergency departments is not straightforward.
A recurrent theme in health policymaking, both in the UK and other similar economies, is the search for ‘appropriateness’ in response to demand. The logic of this is sound: hospital-based care is the most expensive form of care, therefore it should be used as sparingly as possible, to maximum effect. The search for innovative ways of meeting this challenge has to be constant. The Health Foundation’s Innovating for Improvement programme aims to help teams do precisely this. It includes a project using video conferencing to make the best use of scarce psychiatric capacity in emergency departments in Oxford, and another in Sussex, working with community pharmacists to monitor the physical impact of certain medications prescribed to children and young people, rather than sending them to busy child and adolescent mental health services.
It is challenging to know what ‘appropriate’ levels of demand look like. Analysis of linked data with matched control groups, such as that conducted by the Health Foundation’s data analytics team can help disentangle what’s real, unavoidable demand (that requires more resources) from demand created by poor management and lack of prevention. But the intolerable pressure driven by this winter will, hopefully, act as a powerful spur to better understand demand at all levels of the system.
Ruth Thorlby is Assistant Director of Policy at the Health Foundation