Although we are painfully familiar with ‘winter pressures’ there has been a glut of reports highlighting the pressure on the NHS this summer – summer pressures.
This weekend the Institute for Fiscal Studies said that the waiting list for elective surgery could balloon to 14 million procedures by this autumn. Currently, there are 5m people waiting for surgery. The difference relates the millions of ‘missing patients’ who would have, in a normal year, joined the waiting list but due to the pandemic have not come forward or are not yet on the list.
Hospitals and ambulance trusts have been reporting OPEL alerts at level 3 and 4 as they struggle to cope with unplanned admissions. It was predicted back in the early days of the pandemic many people who didn’t seek care at that time would start to present to health services through emergency pathways. Primary care is also experiencing the impact with many struggling to cope adding further pressure on A&E. Some GP practices are reporting that they may need to close or reduce services due to concerns about their ability to provide safe care under such a volume of demand. Staff challenges are also impacting with Newcastle upon Tyne Hospitals Foundation Trust closing 10% of its beds due to staff absences.
Looking at this from a distance it all feels overwhelming and paints a particularly bleak picture for this winter. The challenge ahead – to provide care for covid, seasonal flu, as well as support the restart of electives is no small feat. The simple truth is that regularly hospitals are operating with no spare beds at all. At the centre of all of this is patient flow – making sure patients are moving into services when they need and out as soon as they can.
It was therefore a welcome intervention from NHS Providers last week who called on the government to maintain funding for discharge to ensure that it is made as easy as possible to move medically optimised patients into rehab beds in the community. The emergency funding for hospital discharge removed the artificial barriers which were slowing down discharge – as Chris Hopson notes before the pandemic it wasn’t unusual for 20-30% of beds to be occupied by patients who were ready to move on.
This funding is important, but it is not alone enough to solve the epic demand related challenge for the NHS this winter. And it’s vital to note that capacity in the community is not infinite. Where that capacity is providing complex care, it is in very short supply indeed. Therefore managing this carefully is critical to maintain flow out of rehab beds and into long term care releasing those rehab beds back for new patients.
But what else can be done? Admission avoidance is driving some of the most innovative and integrated projects in health and care. While efficiencies are being recognised at the backdoor (and there are more to be had) there are also efficiencies at the front door which support flow. Care Coordination is about working alongside patients as soon as they present at A&E, staying in close contact with family and carers, making sure that what these patients need to head back home is sorted and implemented as speedily as possible. In a best-case scenario this results in no bed being needed at all but otherwise it aims to avoid a community rehab bed being used when it is unnecessary. Therefore reducing cost and maintaining that bed for someone for whom it is essential. Critical to this is providing the capacity and dedicated skills to work closely with families and patients helping them to make the decisions and choices which will allow them to move from hospital to home quickly and safely.
Getting through the next eight months will be a rough ride but there is no shortage of innovation and commitment to get care right by utilising resources carefully and implementing innovative structures. The initial phase of the pandemic was a huge learning curve and much has been made of the positive learnings to come out of that difficult time. As we look ahead past summer pressures it is possible with the right funding, partnerships, and systems in place there is every opportunity for us to come out of winter with a better understanding of patient flow and how the front and back door can work differently together.