The warning signs in NHS emergency care

Last week, unreported except by HSJ, the NHS took another important step forward on removing long waiting times from the system. Our waiting list analyst Rob Findlay identified that: “for the first time ever, no provider had more than 100 one-year waiters on its waiting list”. He explained that at the end of February there were just 665 one-year waiters - a year ago the number was 5,653.

‘The NHS’s record on accident and emergency waits, while holding up well nationally, is more patchy and better indicates the pressure building’

The “zero tolerance” fines for providers with one-year waiters which have come into force this year are clearly having an effect; 2013-14 could see the complete eradication of one-year waiters. The numbers are small - but the step would be symbolic.

The overall performance on the 18-week waiting time target is reassuringly steady, despite the inexorable rise in GP referrals. This picture of calm efficiency is a world away from the frothing hysteria over the state of NHS hospitals found in the pages of the tabloids − and much closer to the truth.

But the NHS’s record on accident and emergency waits, while still holding up well nationally, is more patchy and better indicates the pressure building in the system.

Think local

Each week our HSJ Local service sweeps the NHS for signs of change. Within the last few weeks we have reported on United Lincolnshire Hospitals Trust asking the public to only use its A&E as last resort; emergency care performance at trusts as different as Hillingdon and University Hospital of South Manchester hitting a rocky patch; and one-hour ambulance handovers on the south coast. Meanwhile, East Kent Hospitals became the latest trust to declare an “internal major incident” due to high emergency demand.

Now we report that the first three and half months of this calendar year have seen a huge spike in ultra-long A&E waits.

‘Do not be surprised to see trust chief executives volunteering their organisations for reviews’

The truth is England’s hospitals are starting to run ferociously hot. It is emergency care that gets the press. But many trusts report it is the other end of the system which is an even greater problem. Finding places to discharge confused older patients via a social care system tottering under fierce cuts is bewilderingly hard.

We are not quite in warehousing territory yet, but the scattering of patients throughout hospitals to inappropriate wards means some hospitals are beginning to have that feel.

The rising demand from all sources is also ripping through efficiency plans. It drives the use of locums and agency staff beyond desirable limits and can cripple plans for the reuse of the hospital estate.

Avoiding an explosion

What is ironic about this situation is that its solution is relatively well known and broadly accepted: care provided closer to home; better demand management in primary care; improved patient education on self-care and how and where to access the relevant NHS services; a secondary care sector better able to spread its workload around the clock and the week; and so on.

But all of these changes take time and effort − much of which is being consumed in simply keeping the ship afloat. Any change planned now will have no real system-wide effect for at least a year, probably more.

The NHS is not likely to sink anytime soon, but there is a need to acknowledge the problem and adopt tactics to get us through this crunch.

The new system gives the opportunity for those jointly responsible for healthcare economies to call “risk summits” to address problems faced by a provider. Summits are being called, for example, for all 14 trusts being scrutinised by Sir Bruce Keogh’s review of hospitals with high mortality rates.

Do not be surprised to see trust chief executives volunteering their organisations for similar reviews having concluded that a burst of bad press is better than having to deal with the consequences of the inevitable explosion.

• Full coverage of the Keogh review