The Telegraph, 4 January 2018

Andrew Haldenby, Director at Reform, wrote an article for The Telegraph titled ‘This is why the NHS is facing such severe winter pressure’. The article asks how severe is the “winter crisis”? What is causing it? And what should be done to prevent it happening again. The full text can be found below:



This is why the NHS is facing such severe winter pressure

The NHS is under extreme pressure as the New Year begins. Non-emergency operations have been cancelled. Accident and emergency departments in Nottingham and Stoke have reported record number of patients and “third world conditions”.

The situation raises a number of questions: how severe is the “crisis”? What is causing it? And what should be done to prevent it happening again?

Is this a “crisis”?

The NHS has always faced increased demand at this time of year, and this is often described as a “crisis”. Most obviously, there is a greater prevalence of flu and the winter cold encourages other illnesses, particularly among elderly people. A doctor friend told me that, when he was in hospital training 35 years ago, he was required to not take leave in January for exactly these reasons.

It is, however, clear that the level of pressure has increased. The clinicians that I spoke to yesterday reported that this winter already feels harder than last, a view also picked up by the BBC’s respected health editor Hugh Pym. Theresa May, also speaking yesterday, was at pains to say that this is not a “crisis” on the grounds that the Service has plans in place, like cancelling non-emergency operations, to enable hospitals to cope. From the patients’ point of view, however, it is quite wrong that such extreme measures are needed to cope with an entirely predictable annual event.

To what extent is this a consequence of an ageing population?

The ageing of the population is a partial factor given that the majority of the increased emergency admissions to hospitals will be elderly people. The proportion of the UK population aged over 65 is 20 per cent this year, rising from around 17 per cent in the last decade. That figure will increase to nearly 30 per cent in 20 years’ time. This need not be a problem in itself, however, if the NHS changes how it operates.

And problems in the social care sector?

Part of the challenge for the NHS is the failure to develop services for elderly people outside of hospital. This means that far too many elderly people are treated in hospital, and then remain there when they need not. The number of unnecessary days spent by elderly people in hospital because of a lack of appropriate community-based solutions for social care has doubled in the last seven years.

The biggest single reason is a lack of care packages for people in their own homes. Theresa May has rightly acknowledged that the situation in social care is unsustainable. The Government’s new ideas, however, are long overdue. A system of compulsory saving is likely to be part of the answer.

Does the NHS itself have to take responsibility due to poor management?

Certainly hospitals can organise themselves better. Some hospitals have pioneered specialist frailty units, based in accident and emergency, to treat elderly patients more effectively. Others have based GPs in A&E units to identify quickly those patients who don’t actually need emergency treatment. Still others are forming partnerships with innovative health companies such as Circle to improve rehabilitation for patients after operations.

Is it patient behaviour, or something more fundamental?

The increase in demand at accident and emergency units is the most important factor of all, because it reveals the root cause of the problem. Since the last years of the Blair government, the NHS has known that driving ever more patients into hospitals will, in the end, be unsustainable. Despite this, the number of accident and emergency admissions in England has risen by 20 per cent, to nearly 6 million per year, over the last 10 years. The number of total hospital admissions has risen by nearly 40 per cent. It is difficult to see how the winter pressures can be stopped while the relentless rise in hospital activity remains unchecked.

Two days’ ago NHS leaders asked the public to play their part by “using the NHS responsibly”, for example by phoning the 111 number or by visiting a pharmacist rather than visiting A&E. In fact the increase in hospital attendances is due not to irresponsible patients but to the basic underlying problems in the way that the NHS operates.

It remains a system geared to spend money on hospitals rather than to develop GP services which would give patients different options. It also woefully under-invests in services to prevent ill health and to increase the resilience of older people.

The solution to the winter pressure lies in a committed push for change by those NHS leaders rather than different choices by patients.

Surely extra money would solve this?

Extra resources would make a difference in the short term, for example by employing extra agency staff. Without fixing the underlying issues in the Service, however, any extra space in hospitals will be inexorably filled up well before this time next year. Without reform emergency extra resources will not prevent the return of winter pressures in 2019 and thereafter.

To the great credit of the NHS leadership, it has a brave plan to rebalance the NHS away from overcrowded hospitals and towards reinvigorated primary care.This week’s events, however, are more evidence that the delivery of that plan has been far too slow.

Theresa May’s job is not to prepare for next year’s winter “crisis” but instead to push those leaders to turn their ideas into action. Even given the demands of the Brexit negotiations, the Prime Minister has given too little leadership on some domestic policy questions, including the future of the NHS.

Stronger leadership from her in 2018, which marks the 70th year of the NHS, could ease the pressure on doctors and patients next winter.

Andrew Haldenby, Director, Reform. This article was originally published in The Telegraph on Thursday 4 January 2017.