Numbers don’t lie – but do they really tell the full story? So far, our winter pressures blog series has looked at what the available data tell us about NHS performance. NHS England publishes monthly performance reports all year round, but since the winter of 2010/11 additional winter monitoring data are also available. Between December and February, acute trusts provide daily updates, and the collated results are published every Thursday. These weekly ‘sitreps’ help provide transparency and, together with weekly flu stats from Public Health England, often drive media headlines. These statistics give us a snapshot, but not the full picture. In this blog, we consider areas where having more or different data might give us a more holistic overview of the impact of winter on health and social care.
What’s happening to GP workload?
Although pressures in hospitals make the headlines, the vast majority of patients’ interactions with the health service take place in general practice. It’s a service under huge strain all year round. But we don’t know at a national level how many additional patients are seen in winter, what they come in for, how many patients try but fail to get seen, or what really happens to the workload of GPs and other community staff (such as district nurses) in winter.
It’s never quiet at my London GP surgery, but since Christmas it has felt even more strained than usual. My hunch is that the pressures widely reported in hospitals are painfully felt in the community too, but we don’t have comprehensive data to show what this means in practice.
What about pressures on social care?
It’s not just for community NHS services that we lack data. This year the number of delayed discharges has fallen, with December 2017 seeing an average of 4,668 patients per day in hospital beds despite being medically fit to be discharged. A major factor in these delays remains the overstretched and under-resourced social care sector, but we have no real-time data on the sector’s capacity at national, regional or local level.
Overall social care bed numbers can be gleaned from the CQC State of Care report, but this isn’t real-time data. With hospital bed occupancy extremely high, delayed discharge numbers hint at the magnitude of the problem. But we don’t know how many nursing home or residential beds are available to move patients into, how this varies by locality, and how much capacity the domiciliary care sector has to respond to the winter peak in demand.
What additional data might we want from hospitals?
NHS England’s weekly performance reports consist almost entirely of data from acute trusts, but contain surprisingly little data to tell us what is happening within hospitals. Pressures on beds mean that hospitals may be forced to ‘outlie’ patients – placing them in wards not specifically set up for their conditions, sometimes far away from the clinical teams looking after them. Care for these outlying patients could be compromised, and it also creates additional pressures for clinical teams, yet there are no national data on the number of outliers at each hospital, nor on whether these patients are more likely to suffer harm.
The media have also reported cases of hospitals running out of essential equipment such as ventilators, but there are no public data on how widespread these shortages are. Patient safety issues may well be known and acted upon at a local level but we might reasonably worry that a lack of central data is a significant blind spot.
More illness, or more complex illnesses?
Winter pressures aren’t just about absolute numbers, they’re also about the increasing complexity of patients’ conditions, much of which remains a mystery. Hospitals report all their activity into hospital episode statistics, but there is a data time lag. Recent studies have looked at what age groups and conditions are driving the rise in attendances and admissions, and which population groups are at greatest risk of being admitted in winter, but analysis of this kind is not available quickly. As A&E departments warn that they are struggling to cope, it’s crucial to understand the drivers of demand, to help us to think about how services could be improved to better meet need.
What’s going on with cancellations?
NHS England publishes quarterly data on cancelled elective operations. These only include ‘last-minute’ cancellations – defined as on or after the day the patient was due to be admitted to hospital. This winter, hospitals were urged to cancel patients with as much warning as possible (and all elective surgery in January was postponed). These won’t be counted as last-minute cancellations, and we do not have reliable data on how many patients have been affected, and for what conditions. The impact of such widespread cancellations is unknown both in terms of harm to patients, and the logistics of delivering 12 months of elective surgery in the remaining 11 months of the year.
What is the impact on patients?
There have been well-publicised reports of deaths this winter attributed to delays in the availability of adequate care. But it is impossible to know how many deaths in winter are avoidable, and how pressures on services might harm patients. Strained services might translate into worse experiences of care for patients, but as winter-specific patient experience data are not collected, it is difficult to understand how services are actually experienced by those who use them.
What is the impact on staff experience?
Although we get weekly updates on the number of hospital beds available, we have little to no information on who is available to staff them. There is an expectation that hospitals report on nursing staffing rates on their wards, but this information isn’t currently aggregated at national level. Shortages of essential staff (including nurses, GPs and A&E specialists) and workforce planning challenges are well known, and it is likely that winter puts additional pressure on already stretched NHS workers. How this affects patient safety, staff morale, recruitment and retention is unknown.
How can we check our blind spots?
Weekly reports, though hospital-centric, have signalled that our whole health and social care system is under pressure. A wish list of data extends well beyond the areas I’ve mentioned above, but it is clear that we are some way from a holistic understanding of how winter affects the system.
There’s a growing consensus that without more funding, winter pressures may become the norm all year round. We know that there are data blind spots not just for hospital care, but also community services, NHS staff, and – perhaps most importantly – the safety and experience of the patients we treat. Better data would help us paint a more accurate picture of where we currently are, and develop a more nuanced understanding of where resources and support would be best directed to ensure maximum benefit for patients.
Dr Becks Fisher (@BecksFisher) is a GP and Clinical Fellow at the Health Foundation