The long term plan must break the cycle of winter crises

Winter is looming. With preparations for the cold weather now firmly underway the inevitable questions arise – how will the NHS fare this winter? Will it be worse than last year?

Each year trusts prepare extensively for winter, and that is certainly the case again this time.

As in previous years, some trusts received some extra money in the autumn to help them prepare. An additional £145m of capital funding was brought forward from the Budget to support projects before the end of December.

Many trusts are now increasing capacity, improving patient flow, reducing length of stay, making changes to patient pathways and working collaboratively across systems to manage demand differently.

Despite these initiatives, the relentless rise in demand has meant that the gap between what health and care services are being asked to deliver and what they are able to provide continues to grow. These pressures are now felt all year round.

Our report Steeling ourselves for winter 2018/19 warns that the coming winter is likely to be even more difficult than the last for trusts, staff and patients.

But why?

Demand/capacity gap

Accident and emergency performance against the four hour target has dropped significantly compared to last year as the rise in demand exceeds the capacity available. The pattern over the last five years suggests this will continue throughout winter so we can expect to see more people waiting longer.

Demand for elective care is also on the rise. The number of people on the waiting list has risen to 4.15 million – the highest on record. Performance against targets for cancer and diagnostics has also deteriorated over the past six months.

Much of the resource and energy over the winter period goes into meeting demand for emergency care. Hospital trusts no longer have the ability, as they did in the past, to successfully juggle performance across different activities, using over performance in some areas in the summer months to prioritise emergency care in the winter months.

This accelerating demand/capacity gap is system wide; stretching services in primary and social care and community, ambulance and mental health services as well as hospital trusts.

The £240m funding that was recently announced for social care will bolster some of the sector’s plans for this winter by supporting more timely discharge, but the need for a longer term social care funding settlement to tackle rising demand remains.

The steep rise in demand for services sits against the backdrop of workforce shortages

The steep rise in demand for services sits against the backdrop of workforce shortages. Both social care and the NHS face severe difficulties with recruitment and retention. Vacancies are expected to rise for the rest of the year.

This means trusts may find it harder than last year to bring in and keep the staff they need to cope with added winter pressures. That could place the existing workforce under even more strain – a serious risk for a service that is already heavily reliant on discretionary effort from its staff.

And following a particularly difficult summer, trusts are already finding it more difficult to secure the same level of extra shifts as last year.

The position in which trusts currently find themselves highlights the frustrating paradox of frontline staff pulling out all the stops to cope with growing pressures, but slipping further and further from the constitutional standards the public have been told to expect.

If system and service transformation is viewed as the key to reducing pressure on urgent and emergency care and move care closer to home, the pace of change needs to accelerate.

Long term plan

The announcement of a long term funding settlement for the health service promises the first real boost in NHS spending for some time. The long term plan provides an opportunity to break the perpetual cycle of winter crises.

It must deliver a sustainable workforce so we are not in this position again in 20 years time.

The long term plan must also facilitate more investment and greater pace and consistency in the joining up of local health and care services so that they can provide care in new ways

The long term plan must also facilitate more investment and greater pace and consistency in the joining up of local health and care services so that they can provide care in new ways.

In particular, the plan must tackle the needs of the increasing older population and have specific emphasis on how to support more patients in their own homes or local community, rather than in hospital when they don’t need to be there.

But for now, trusts and their staff will continue to do all they can to meet the challenges of winter, go above and beyond to deliver competing priorities, and work with system partners to provide safe, timely care whatever pressures they may face in the months ahead.