By Susan Adams, CHS Healthcare manager, south England
The myriad of “winter pressures” on the NHS is evident each year, but the exact interplay of the different causes is challenging to understand. This winter, we have already had familiar scenarios of ambulances waiting outside accident and emergency departments, unable to handover their patients to hard-pressed units. A&E performance is regularly presented as a ‘litmus’ test for NHS resilience. Yet there is not a straightforward equation of winter producing more sickness and therefore more patients arriving at the front end of hospitals. As the Kings Fund states, emergency attendances are typically lower in December and January than during the summer. Whether winter admissions are sicker and more frail during winter is certainly the case for a significant number, but hard to quantify overall.
What we do see, in a clear and measurable way, is the impact of the Christmas holiday period upon discharge capacity as a whole. CHS Healthcare provides discharge co-ordination services in 35 NHS acute hospitals across England and it is observable that in some cases, the impact of Christmas commences in November. Last year in the south-west, for example, where we co-ordinate Fast Track care for patients whose wish is to return to their own homes for their final weeks of life, one major domiciliary care provider told us early in November that they would not be able to provide any new packages of care for 12 weeks. This pattern has been repeated this year: a continuing healthcare lead in the south-east stated that if home care was not in place very early in December, there would be no likelihood of it being provided before the New Year. Why this sudden fall in home care capacity? Domiciliary care is provided by low paid workers who are often on zero hours contracts. Many choose to work fewer hours over Christmas, often because they cannot afford the high costs of childcare while their children are off school.
An operations planner in the Midlands suggests that this fall in whole system discharge capacity over the Christmas period means that at the start of January, when social care operations are returning to normal capacity levels, there is such a backlog of patients from the November and December delays that the whole system is unable to ‘catch up’ for many more weeks.
What can we do? In our service for Fast Track patients in the south-west, we had to find compromises: patients who wanted to be in their own homes with support for their final weeks were very sadly unable to do so, but to remain in hospital was a particularly poor option, so we sought good nursing home places. This too was difficult as capacity here was also limited. We provide a consistent focus on the discharge process, which is ever more critical when capacity tightens. Regularly, we make 30 or 40 phone calls per discharge, we have advisers visiting care homes to ensure managers come to hospital to assess, our evaluation shows how we routinely ‘go the extra mile’ to make a discharge happen during this tricky Christmas period (whose effect can be seen potentially from November deep into January).
Of course, this is only one element of winter pressures and there are many more. This is a common theme of discussion among discharge teams, yet it is rarely aired more widely and illustrates how a traditional holiday period can drive pressures, both with and without any accompanying rise in cold related sickness.”