The crisis in our hospitals

"NHS in crisis" headlines have become an annual event. But are things really as badas all that? Simon Wilson reports.

What's happened?

The new year has kicked off with acres of media coverage about a 'crisis" in the NHS across the UK, and especially in England.

Of course, tales of NHS crises have become a January tradition in recent years, and the start of 2015 has also coincided with the start of the general election campaign (and Labour's drive to 'weaponise' the NHS).

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However, this year there has been far more substance to the media frenzy than normal. Last week, official figures showed A&E departments in England have recently turned in their worst performance since the current metrics were adopted ten years ago.

What are the figures?

In the three months from October to December, only 92.6% of patients in England were dealt with by A&E departments within the target of four hours, compared to the goal of 95%. For big A&E departments specialising in major trauma, the figures were even worse, with only 88.9% of patients treated and then admitted or discharged within four hours.

The statistics for Wales and Northern Ireland are even poorer, while Scotland is not faring much better. Then, last week, data for the start of 2015 showed the proportion (for all A&Es in England) had dropped to a new weekly low of 86.7%.

And in the two weeks over Christmas and New Year, nearly 21,000 A&E patients waited for up to 12 hours on trolleys almost four times as many as the same period last year. Overall in the last three months, more than 90,000 A&E patients waited for up to 12 hours on trolleys.

How does that compare with the usual figures?

It's the highest in a decade and more than 40% higher than the previous high, in spring 2013. The pressure on the system has led at least 12 hospitals to declare "major incidents" in recent weeks meaning they were unable to cope with the sheer numbers of people turning up at A&E.

To compound the sense of panic, at the end of last week the first (and only) private operator of an NHS hospital pulled out of a ten-year contract to manage Hinchingbrooke Hospital in Cambridgeshire after less than three years. Aim-listed Circle Holdings blamed rising A&E numbers and a 10% cut in government funding to the trust that manages care.

What's going on?

The core issue is rising demand more people turning up at A&E, especially the elderly and more problems with getting patients out at the other end ('delayed transfers', or 'bedblocking'). So far, this financial year has seen 400,000 more A&E visits (about a 3% rise) compared to the same time last year.

This rise has been blamed on a mix of factors: a more individualist society in which patients expect immediate treatment; the GP contracts negotiated under Labour that severely limit out-of-hours services; an ageing population; and problems with NHS 111, a phone line staffed by call-centre staff (rather than clinicians) whose box-ticking algorithms are based on worst-case scenarios that prompt them to send too many to A&E.

What about the other end?

Robert Colvile, who spent a week in the A&E department at the state-of-the-art Queen Elizabeth Hospital (QEH) in Birmingham, wrote an outstanding long report on his observations for The Daily Telegraph. He notes that delays in getting patients out of hospital are just as crucial as rising demand.

Why does it take so much effort to free up a bed? Mainly because most patients who end up staying in hospital after arriving at A&E are elderly, and many of them can't just go back to their homes. "They need places at nursing homes, or rehabilitation programmes, or other packages of care. Keeping that flow going is what keeps a hospital alive but they have absolutely no control over it."

Why not?

Because social care isn't run by the NHS, it's run by social services, which answer to councils "whose own budgets have been slashed even as the health service's has been ring-fenced".

Also, the structure of the NHS means the "delayed discharged" problem is worse than it has to be. Clinicians at highly regarded hospitals, which attract patients from far beyond their official catchment areas, have to liaise with whole new sets of social-services staff, many of whom prioritise patients for discharge from their own local hospitals.

The average length of stay in the QEH for patients from Birmingham is 12 days; for those from outside it is 20. "In periods of pressure, everybody gets quite parochial," says Andrew McKirgan, a senior NHS manager in Birmingham. "The hub and spoke starts to disintegrate because everyone's retrenching to their own local boundaries."

What is to be done?

Any solution to the A&E issue has both to deter unnecessaryvisits and better manage the flow of patients. But it is alsoabout money.

First, says Robert Colvile in The Daily Telegraph,the overly complex system of internal market "tariffs" payments made each time a patient moves along their clinical"pathway" creates perverse incentives that reduce efficiencyand push up costs.

Second, says Nicholas Timmins in the FT,the current debate is all about "NHS cash, when it needs to beabout health and social care spending combined".

What maybe needed is major reform, bringing health and social carespending together in a single, ring-fenced, budget. Only thenwill the NHS be in a position to keep providing the quality ofcare Britons have come to expect.