Monday, 12 January 2015

A&E crisis: major incidents risk being the new normal for the NHS

With lengthening waiting times, a surge in demand and a lack of staff, it seems reasonable to suggest there is a systemic problem.

NHS trusts will have to make tough choices about their future2014 was the year the cracks began to show in the NHS

here could scarcely have been a more explosive start to 2015 for the NHS, with all media outlets leading on the flurry of major incidents declared at hospitals nationwide. Politicians responded accordingly – David Cameron downplayed it as short-term pressures while Andy Burnham called for an all-party emergency summit. But what exactly is going on? Are we talking about a handful of rotten apples or is there a systemic problem?

Part of the answer can be found in the number of declarations that steadily grew from two or three to about 20 within a few days. Even this will be an underestimate as other hospitals will surely have been facing similar problems but decided against the reputational damage of a formal declaration.
With waiting times at A&E lengthening, and knock-on effects to the 18-week wait target for hospital treatment kicking in, it seems reasonable to suggest there is a systemic problem. But what is it?
Most of the analysis has focused upon factors external to hospitals – problems at the back door rather than the front door. Hospitals have significantly reduced the time needed to recover from clinical interventions but then find hospital flow is blocked by limited discharge options – families unable or unwilling to cope, access to social care support collapsing under the weight of public spending cuts and third sector organisations struggling to survive. All of this was entirely foreseeable.
Less clear is the factors behind some of the surge in demand. The larger population and its ageing cohort are important, but over the last decade or so there have been 60% more hospital admissions than would have been expected as a result of these changes.
Some have pointed to the emergence of a “right now” attitude among younger people who are bigger proportionate users of A&E than older people. The algorithm staffers at NHS 111 are said to be sending around a fifth more people to A&E than the former NHS Direct, and quick GP appointments in some areas are still a collector’s item. And all of this is happening before any of the traditional winter illnesses are taking effect.
This surge in demand from patients has coincided with a diminished supply of staff to treat them. GPs are retiring or leaving the NHS to work overseas, district nurse numbers have dwindled to the point of extinction, doctors and nurses are shunning a career in A&E. Under the cosh of the Francis report, hospitals have increased nursing numbers but only by taking on expensive agency staff or scouring other countries and poaching their staff. This additional recruitment is unfunded, leaving hospitals to choose between quality of care or financial insolvency.
Although much of the debate has rightly focused on the absence of community support for people ready for discharge from hospital, less attention has been given to the ways in which hospitals themselves have been financially compromised. Many are struggling to cope with the long-term legacy of extortionate private finance initiative schemes.
On top of this, all are subject to penalties for the use of A&E facilities above target level and for readmissions within 30 days, even though payment for all A&E cases is fixed at only 30% for activity increases higher than the level seen in 2008-9. In effect, hospitals are being compelled to pay the price of wider weaknesses in the local health economy over which they have little or no control.
Meanwhile cash-strapped clinical commissioning groups demand more for less from their local providers and Monitor imposes punishing and unachievable efficiency tariffs.
The upshot of all of this is widespread financial unsustainability across foundation trusts and NHS trusts. About 25% of NHS trusts are thought to have been in deficit in 2013-14 (compared with 5% in 2012/13) as are 27% of foundation trusts (compared with 14% in 2012-13). Others will be eating into their rapidly diminishing reserves. We can expect even worse figures for 2014-15 when they are published, at which point quality of care will be comprehensively trumped by financial insolvency.
Where do we go from here? The current strategy is hasty pre-election bungs to forestall the worst events. Hunt has also pointed to the introduction of named GPs (little more than a gimmick) and the creation of the Better Care Fund (robbing Peter to pay Paul). All political parties are offering post-election spending increases for the NHS but none are even reaching the minimum £8bn figure proposed by Simon Stevens in his recent Five Year Forward View.
This leaves us with a partially-funded remodelling of the NHS along the ambitious lines proposed by Stevens – variations of “whole system working” without the help of a “transformation fund” and still set in the market-based ethos of the 2012 act.
Monitor, the competition watchdog, is already making worrying noises about the need for competing integrated care providers. The Stevens bandwagon will roll on – vanguard sites have until the end of this month to get their bids into NHS England – but only optimists will feel a surge of confidence about the future. The issues are so deep-rooted, complex and inter-linked that tinkering will do little to help. Some hospitals are more robust than others, but sacrificing a few rotten apples isn’t the problem. The whole barrel needs to be changed otherwise major incident will be the new normal.
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