Is now the winter of our discontent? Exploring seasonal pressure on the NHS

My Post (1)Around this time every year, the media is strewn with forewarnings of how winter will put undue strain on the NHS. In a system already struggling to cope, there are concerns that the seasonal pressure pushes services to breaking point. The NHS’s ability to handle yearly increases in demand has led the British Red Cross to go as far as to call it a ‘humanitarian crisis’ (Campbell et al, 2017).

This article will consider the causes of winter pressure on NHS services and how they differ to those experienced throughout the rest of the year. It will explore whether the warnings are genuine or mere hyperbole, and look at some of the ways the NHS attempts to combat these pressures.

Causes of winter pressures

The leading cause of winter pressure is difficult to pinpoint, and can vary from year to year. However, there are a number of recurring contributing factors. While most health problems are not caused by extremes of cold, the weather indelibly has an effect on the number of patients attending accident and emergency (A&E) departments.

Cold weather increases the risk of heart attacks, strokes, respiratory illnesses, flu, falls and other diseases (NHS England, 2013; Public Health England, 2017). Vulnerable people— such as the very young, elderly and those with pre-existing conditions— are those predominantly affected by changes in the weather (National Institute for Health and Care Excellence (NICE), 2015). The effect of winter on the NHS becomes apparent in early December. Performance in A&Es is measured through their ability to meet a 4-hour waiting target. One of the core standards of the NHS Constitution states that a minimum of 95% of patients attending A&E departments in England must be seen, treated and then admitted or discharged in under 4 hours (NHS England, 2015). Breaches of the 4-hour waiting standard result in trusts having to pay penalties (House of Commons Health Committee, 2016).

A&E attendances
Annual attendances at A&E departments have increased. The number of people arriving at major (type 1) A&E departments has seen a 7% rise from 2010 to 2015—from an average of 36 731 attendances per day in August 2010, to 39 220 in August 2015 (Fisher and Dorning, 2016).

Consequently, only 87.9% of patients in type 1 departments were admitted, transferred or discharged within 4 hours in 2015–16 (House of Commons Health Committee, 2016). This is clearly far below the expected standard. The Royal College of Emergency Medicine (2016a) has estimated that the increased attendance over the past 5 years is equivalent to the workload of 10 additional medium sized emergency departments.

Contrary to expectation, the highest number of A&E attendances does not take place in winter. Instead, there is an observable ‘dip’ in visits to A&E around December and January (Fisher and Dornin, 2016). The highest overall attendances are actually in the summer months. The important factor affecting winter pressure is the number of patients subsequently admitted to hospital. The highest proportion of the patient population in summer is under 60 years of age. By contrast, in the winter, it tends to consist of those over 60 years. This spike in the number of more vulnerable, elderly patients is significant because they tend to stay longer in A&E, and are more likely to be readmitted to hospital (Fisher and Dornin, 2016).

Hospital admissions
Like attendances, hospital admissions have also increased. Similarly, they have seen a 7% rise from 13 723 in August 2010 to 14 666 in August 2015 (Fisher and Dornin, 2016). There is a notable ‘peak’ of admissions during the middle of winter (Fisher and Dornin, 2016).

The difference between the proportion of patients admitted is 27.9% in winter, compared with 25.8% in the summer months (Department of Health (DH) et al, 2017).

‘Congestive hospital failure’
The rise in hospital admissions has caused a subsequent decrease in the number of available hospital beds, with the percentage of beds occupied peaking in winter (Fisher and Dornin, 2016). Due to the number of beds available for admission of acutely ill and injured patients continuing to fall over the past 5 years, the UK now has the lowest number of beds per capita in Europe, and England has the lowest number within the UK (Royal College of Emergency Medicine, 2016a). The consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11, to 91.2% in 2015–16 (Royal College of Emergency Medicine, 2016b).

A lack of available beds reduces flow through A&Es as it slows the accommodation of new attendances (Royal College of Emergency Medicine, 2016a). This in turn affects the ability of ambulance services to off-load patients—an issue known as ‘congestive hospital failure’ (NHS England, 2013).

Another factor influencing occupancy rates is delayed transfer of care, which leaves systems less resilient to operational pressures. Unnecessary delay in discharging patients who no longer need to be in hospital led to 1.15 million bed days being lost in acute hospitals during 2015 (National Audit Office, 2016).

Combatting pressures

To help combat winter pressures, the NHS conducts strategic planning each year. For the 2017/18 winter, formal planning began at its earliest time yet in July (Philip, 2017). Local plans were submitted in September covering resilience arrangements from the start of December up to Easter 2018.

As part of this preparation, Public Health England (2017) publishes a Cold Weather Plan every year to help protect the population against harm from cold weather. A mixture of past experience and forward-planning will help build future resilience. Below are some of the key methods of combatting pressure.

Best use of ambulance services
An expansion of the ‘hear and treat’ and ‘see and treat’ services provided by ambulance services can help alleviate demand on A&E departments. ‘Hear and treat’ services refer to 999 calls that are successfully completed without dispatching an ambulance vehicle response. Examples of this include over-the-phone advice, instructions for self-care, or referral to other urgent services (Urgent and Emergency Care Review Programme Team, 2015).

‘See and treat’ services refer to a model of care where a patient is clinically assessed at scene, before being provided with immediate treatment and subsequent discharge and/or referral (Urgent and Emergency Care Review Programme Team, 2015). By avoiding taking patients unnecessarily to A&E, they can be referred to more appropriate services that better fit the patient’s needs, or further support can be provided at home or in a community setting. ‘Hear and treat’ and ‘see and treat’ services now cover 3.5 million people (NHS England, 2017b).

This winter will see the full rollout of phase two of the Ambulance Response Programme, with the introduction of new call standards that accurately reflect the type and urgency of care needed by patients (Quaile, 2017). Along with the new dispatch on disposition system, giving call handlers more time to triage 999 calls, it is hoped that many patients can avoid being taken unnecessarily to A&Es.

Boosting flu vaccinations
Flu outbreaks within health services can be crippling and are a genuine concern each winter. Last year, 49% of NHS staff were vaccinated against the influenza virus and, this year, the number of vaccinated staff has been raised to 63% (NHS England, 2017b).

Additionally, free flu jabs will be provided to hundreds of thousands of care-home staff at a cost of up to £10 million; and numbers of vaccinations for young children and vulnerable people will be increased (NHS England, 2017a). Being vaccinated is the best way to prevent the spread of flu infection and reduce avoidable deaths. As it is possible to have flu without showing any symptoms, health professionals could find themselves working with flu but not realising it. It is essential they are vaccinated to avoid spreading the illness to vulnerable people.

Increasing funding
The spring budget announced an additional £100 million to support improvements in emergency departments through the implementation of a primary-care streaming model (Philip, 2017). Here, patients are streamed away from highly pressured emergency departments, to co-located GP-led primary care services, for conditions more suited to assessment and treatment in primary care (NHS Improvement, 2017).

Achieving ‘good’ patient flow
According to Monitor (2015), improving patient flow through hospital departments other than A&E is ‘the most important systemic means’ of avoiding sharp declines in A&E performance during winter. Health systems that have better patient flow are much better at coping with external pressures than those who don’t (NHS Improvement, 2017). Within ambulance services, good patient flow is seen as the handing over of a patient to an emergency department within 15 minutes of arriving (NHS Improvement, 2017).

My Post (2)Encouraging self-care
Further promotion of self-care is essential to reducing demand on health services. Giving people the confidence and information to look after themselves can help prevent ill health and reduce pressure (British Medical Association, 2016). However, for this to work, support needs to be easily accessible.

Improving housing conditions
Housing conditions for vulnerable people play an important part in the number of excess winter deaths and illnesses. In the coldest 10% of homes, the death rate rises approximately 2.8% for every degree Celsius drop in the outside temperature (NICE, 2015).

In England, there is a relatively sharp increase in the risk of death when outdoor temperatures fall to around 6°C (NICE, 2015). Improving heating and insulation for vulnerable people is therefore highly important for reducing avoidable illness or death.

Addressing growing GP demand
General practice is on the brink of crisis as a result of inadequate resourcing, an insufficient workforce, and an unsustainable workload (British Medical Association, 2016). The number of GP consultations in England rose from 303 million in 2008/9 to 361 million in 2013/14 (Royal College of General Practitioners, 2015). However, despite this 19% increase in demand, there has been no change in resourcing and staffing, putting undue strain on GP services (British Medical Association, 2016).

Increased funding in social care
Social care has been struck by considerable funding cuts in recent years, creating a knock-on effect on the number of people receiving services.

There were 500 000 fewer people who accessed social care in 2013/14 compared to 2008/9 (Franklin, 2015). This is despite an increasing ageing population, where the number of over-85s will double over the next two decades. It is also anticipated that adults with a learning disability will increase by at least a third (Local Government Association, 2016).

The cut of £5 billion in local authority social care budgets over the last 5 years has placed significant pressure on services (Local Government Association, 2016). Delays in arranging community nursing or social care has a considerable impact on delayed transfers, with 60% of trusts believing the increase in delayed transfers of care is owing to reductions in social care capacity (Monitor, 2015).

Conclusion
This article has sought to explain the reasons behind additional pressures on health services brought on by the winter season. While attendances at A&E are lower during the winter, the number of hospital admissions of vulnerable patient groups rises, largely because of seasonal illnesses such as flu and norovirus. This causes a reduction in the number of beds available and reduced patient flow within hospitals.

To combat these pressures, longer term investments are needed to address the insufficient workforce, lack of social care, and demand on primary care services. Although there has been additional investment in vaccination against flu; primary-care streaming; and resilience funding for ambulance services for this winter; it is unclear what impact—if any—this will have on health services.

References

British Medical Association. Beating the effects of winter pressures: Briefing paper. 2016; London: BMA

Campbell D, Morris S, Marsh S. NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns [Internet]. London: The Guardian; 2017. [cited 2017 Oct 23]. Available from http://tinyurl.com/y73vemzg

Department of Health, NHS England, NHS Improvement. Written evidence submitted by the Department of Health, NHS England and NHS Improvement (WIP0035) [Internet]. 2017. [cited 2017 Oct 23]. Available from http:// tinyurl.com/y7vlmu5r

Fisher E, Dorning H. Winter pressures: what’s going on behind the scenes? London: Quality Watch; 2016

Franklin B. The end of formal adult social care: A provocation by the ILC-UK. 2015; London: ILC-UK

House of Commons Health Committee. Winter pressure in accident and emergency departments: Third Report of Session 2016–17. 2016; London: The Stationery Office

Local Government Association. Adult social care funding: 2016 state of the nation report. 2016; London: LGC

Monitor. A&E delays: why did patients wait longer last winter? [Internet]. 2015. [cited 2017 Oct 23]. Available from http://tinyurl.com/ ofw2uv3

National Audit Office. Discharging older patients from hospital [Internet]. 2016. [cited 2017 Oct 23]. Available from http://tinyurl.com/hnyuy2p

National Institute for Health and Care Excellence. Excess winter deaths and illness and the health risks associated with cold homes. Clinical Guideline 6. 2015; London: NICE

NHS England. NHS leaders unveil action to boost flu vaccination and manage winter pressures. [Internet]. 2017a. [cited 2017 Oct 21]. Available from http://tinyurl.com/ycp5k8er

NHS England. The Handbook to the NHS Constitution. 2015; London: The Stationery Office

NHS England. Understanding Winter Pressures in A&E Departments [Internet]. 2013. [cited 2017 Oct 21]. Available from http://tinyurl.com/ yblaeduc

NHS England. Urgent and emergency care [Internet]. 2017b. [cited 2017 Oct 21]. Available from http://tinyurl.com/y9dctbsp

NHS Improvement. National priorities for acute hospitals 2017. Good practice guide: Focus on improving patient flow [Internet]. 2017. [cited 2017 Oct 23]. Available from http://tinyurl. com/y7t6mfam

Philip P. Letter to all CCGs and providers regarding planning for winter 2017/18, and other operational priorities [Internet]. 2017. [cited 2017 Oct 22]. Available from http:// tinyurl.com/y82kelxe

Public Health England. The Cold Weather Plan for England: Protecting health and reducing harm from cold weather. 2017; London: The Stationery Office

Quaile A. What’s next for England’s ambulance services? J Paramed Pract. 2017;9(10): 443-444

Royal College of Emergency Medicine. Why does winter in A&E get worse every year? 2016a; London: The Royal College of Emergency Medicine

Royal College of Emergency Medicine. Written evidence submitted on behalf of the Royal College of Emergency Medicine (WIP009) [Internet]. 2016b. [cited 2017 Oct 23].Available from http://tinyurl.com/y8naucxs

Royal College of General Practitioners. Patient safety implications of general practice workload. 2015; London: RCGP

Urgent and Emergency Care Review Programme Team. Transforming urgent and emergency care services in England: Clinical models for ambulance services. 2015; Leeds: NHS England

Taken from Journal of Paramedic Practice, published November 2017.

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How will the election affect the NHS?

The outcome of the general election marks the first Conservative majority Government for 18 years. Despite polls anticipating results between Labour and the Conservatives to be tight, David Cameron’s party achieved a convincing victory. So what effect will a Conservative majority Commons have on the NHS?

Health and social care was one of the key issues addressed during the 2015 general election campaign, and the Conservative Party have committed to spend at least an additional £8 billion on the NHS over and above inflation by 2020 (The Conservative Party, 2015). This is in line with the amount outlined by Simon Stevens in the Five Year Forward View (NHS England et al, 2015) as being required if the NHS is to be sustainable. However, the Conservatives have not yet indicated where this money will come from or how much will come each year.

The Conservatives plan to continue to strive for a truly 7-day NHS, and aim to give all patients access to a GP from 8:00 am to 8:00 pm, 7 days a week by 2020 (The Conservative Party, 2015). They have guaranteed that everyone over 75 years will get a same day appointment if they need one, and have said they will train and retain an extra 5 000 GPs (The Conservative Party, 2015). However, analysis published by the Royal College of General Practitioners suggests that under current systems, patients will have to wait until 2034 for the proposed additional GPs (Rimmer, 2015). The College has estimated that 8 000 more GPs will be needed in England by 2020 to keep up with patient demand, and so an emergency package of measures is needed if this is to be realised (Rimmer, 2015).

Other priorities for the Conservatives include equal priority for the treatment of mental conditions and the need to integrate health and social care systems by joining up services between homes, clinics and hospitals (The Conservative Party, 2015).

The impact for ambulance services of 5 years under the Tories is unclear. However, it is likely that the gradual shift in focus to treat people at home rather than in A&E will see an enhanced role for paramedics. That being said, it will not be easy. While paramedics are well placed to provide additional health services, February saw the profession being added to the shortage occupation list for the first time, as increased pressures brought on by longer hours and growing stress levels have led to many looking for alternative lines of work.

NHS Providers chief executive, Chris Hopson, has argued that until performances and finances are stabilised the NHS cannot transform (Hopson, 2015). Going forward this will undoubtedly be the challenge for the Conservative Government. By addressing these factors as a priority, only then can patient quality of care be ensured.

References

The Conservative Party (2015) Strong leadership. A clear economic plan. A brighter, more secure future. The Conservative Party Manifesto 2015. http://tinyurl.com/q82h3g6 (accessed 1 June 2015)

Hopson C (2015) The new health secretary will face an uphill battle. HSJ. http://tinyurl.com/ovw3j7a (accessed 1 June 2015)

NHS England, Public Health England, Health Education England, Monitor, Care Quality Commission, NHS Trust Development Authority (2014) Five Year Forward View. http://tinyurl.com/kcjenmc (accessed 1 December 2014)

Rimmer A (2015) It will take up to 31 years to deliver number of GPs promised by political parties, says RCGP. BMJ 350: h2472. doi: 10.1136/bmj.h2472

Taken from Journal of Paramedic Practice, published 5 June 2015.

Government rejects proposed 1% NHS pay rise

Around 600,000 NHS staff will receive a lower pay rise than expected following the government’s rejection of proposals to increase staff pay by 1%.

The independent NHS Pay Review Body recommended a 1% rise across all pay scales but ministers have claimed this as an ‘unaffordable’ cost.

Staff eligible for incremental ‘progression pay’ increases on the Agenda for Change framework, which usually average at 3.4%, will not receive a 1% rise on top of this. However, staff due to receive incremental rise of less than 1% will have them lifted to 1%.

Danny Alexander, the chief secretary to the Treasury, said: ‘We need to continue with public sector pay restraint in order to put the nation’s finances back on a sustainable footing.

‘We are delivering on our commitment to a 1% pay rise for all except some of the most senior public sector workers.’

NHS Employers has defended the decision to curb NHS pay. Chief executive, Dean Royles, said:

‘These are really tough calls for the government to make. We know staff have worked incredibly hard in some very challenging circumstances when the NHS has been subject to exceptional scrutiny. For many staff a pay increase would of course help ease some financial pressures and for others a pay award would be a welcome recognition in a difficult year. We know how tough this decision will feel and how disappointed staff will be.

‘The evidence we gave to the review body said any rise would add to already significant cost pressures. Employers are recruiting more front line staff with no additional money and this is not sustainable. The simple fact is that the decision to have no annual pay increase for those already eligible for increments will help ensure more that staff remain in employment than would otherwise be the case.

‘More than two-thirds of NHS spending is on staff and increasing all staff pay by 1% cent would have cost about half a billion pounds, equivalent to around 14,000 nurses. Even with limiting the increase to staff at the top of their pay scales, employers still face a £150 million pay bill pressure this year. This is bound to have an impact.’

Health unions have reacted furiously to the announcement, with Rachel Maskell, head of health at the union Unite, saying that it will ask its members to consider industrial action over the pay award.

She added: ‘[Jeremy Hunt] is deliberately muddying the waters by trying to imply that the annual increment that staff receive, as they gain more skills to benefit patients throughout their careers, is part of the annual pay increase—it is not. It is despicable that Hunt has adopted such an underhand tactic.

‘The [pay review body’s] role is defunct, if ministers continue to steam roller its copious evidence gathering process which leads to its considered recommendations on pay.

‘Hunt has created a parallel pay universe where 2,400 top NHS bosses are earning more than David Cameron—this is a gravy train for the elite, while nurses, health visitors, paramedics and speech and language therapists are treated with contempt.’

Taken from Journal of Paramedic Practice, published 26 March 2014.

Antimicrobial resistance is a ‘ticking time bomb’

The Chief Medical Officer Professor Dame Sally Davies has announced that global action is needed if we are to overcome the ‘catastrophic threat’ of antimicrobial resistance.

The warning, made in her second annual report, highlighted the lack of new antibiotics discovered in the past two decades.

Despite new infectious diseases being discovered on an almost yearly basis, very few new antibiotics have been developed.

This means that we have limited resources to manage the increasing number of infectious diseases that are ever evolving to become resistant to current drugs.

‘We need to work with everyone to ensure the apocalyptic scenario of widespread antimicrobial resistance does not become a reality,’ said Professor Davies. ‘This is a threat arguably as important as climate change for the world.’

The importance of preserving current antibiotics was also emphasized. Professor Davies argued that in order to retain the effectiveness of existing antibiotics, responsible prescribing must be adhered to.

‘All physicians who prescribe antibiotics have a responsibility to their patients (and public health) to prescribe optimally,’ she said.

To help meet the challenges set out by Professor Davies, the Department of Health is planning to publish a UK Antimicrobial Resistance Strategy.

This five-year strategy will focus on championing the responsible use of antibiotics by ensuring NHS staff have the necessary knowledge, skills and training to prescribe antibiotics effectively.

Professor Davies stressed that governments and organizations across the world, including the World Health Organization and G8, need to realize the seriousness of the problem.

‘If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics.’

Taken from Practice Nursing, published 19 Mar 2013.

Why Brains Matter

The Neurological Alliance launched a survey entitled ‘Our Brains Matter’ as part of the 2013 Brain Awareness Week, 11-17 March.

Brain Awareness Week is a global campaign to increase public awareness of the progress and benefits of brain research.

The aim of the Our Brains Matter survey is to develop a clear picture of the experience of being diagnosed with a neurological condition in the UK. With the evidence gathered, the Neurological Alliance will push for improvements in the diagnosis of all neurological conditions.

The Neurological Alliance is the collective voice for 10 million children, young people and adults in England with a neurological condition. It is a membership organization consisting of more than 70 national brain and spine organizations.

The coalition of charities has warned that a ‘legacy of neglect’ is preventing an estimated 12 million people living with neurological conditions in the UK from gaining vital treatment.

According to the Neurological alliance this is due to a lack of specialist knowledge and haphazard services.

‘Around one in six people in the UK will experience a neurological condition in their lifetime,’ explains Arlene Wilkie, Chief Executive of the Neurological Alliance, ‘Yet little is being done to ensure that the NHS is fit for purpose when it comes to responding to these complex conditions.’

Taken from Practice Nursing, published 19 Mar 2013.

LAS improves out of hospital cardiac arrest survival rates

As part of a call to action from health secretary Jeremy Hunt to reduce the number of avoidable deaths in the UK, the Department of Health has published an outcomes strategy on cardiovascular disease (CVD), which will support the NHS and local authorities in delivering improved outcomes for those with or at risk of CVD.

The announcement comes following The Lancet’s recent report on the UK’s health performance, which highlighted that the UK was a long way behind many other countries.

CVD affects the lives of millions of people and is one of the largest causes of death and disability in the UK. However, fast responses to emergencies can save lives and, in some cases, reduce disability.

According to the strategy about 50 000 out of hospital cardiac arrests (OHCA) occur each year in England. Due to a variety of reasons, such as co-morbidity, resuscitation may be inappropriate, and so attempted resuscitation by ambulance services occurs in less than 50% of cases.

However, there is significant variability between ambulance services in rates of successful initial resuscitation (13-27%) and survival to hospital discharge (2-12%) following an OHCA. If survival rates were increased from the overall average (around 7%) to that of the best reported (12%), it is estimated that an additional 1 000 lives could be saved each year.

The strategy revealed that since 2004/2005 the London Ambulance Service (LAS) has improved overall OHCA survival to hospital discharge from a rate of 4% to 11% in 2011/2012. This is as a result of quicker response times; taking heart attack and cardiac arrest patients direct to heart attack centres; and improving bystander resuscitation.

Despite improvement in the LAS, variation in the quality of acute care in other parts of the country mean that much can still be done if patient mortality from CVD is to see considerable change.

The CVD outcomes strategy claims that the NHS Commissioning Board (CB) will work with the Resuscitation Council, the British Heart Foundation and others to promote automatic external defibrillator (AED) site mapping/registration and first responder programmes by ambulance services, and consider ways of increasing the numbers trained in cardiopulmonary resuscitation (CPR) and using automated AEDs.

Taken from Journal of Paramedic Practice, published 14 Mar 2013.

Australia introduces HPV vaccination for boys

Australian schoolboys have begun receiving vaccinations to protect them against cancers and disease caused by the human papillomavirus (HPV).

HPV is a common infection that is associated with cervical cancer and genital warts. It has also been linked with other cancers such as throat cancer, although not as strongly.

‘We’re confident that extending the program to males will reduce HPV-related cancers and diseases in the future,’ said Australian Health Minister Tanya Plibersek.

Following the introduction of the vaccine to girls in 2008 to help reduce the risk of cervical cancer, Australia has become the first country in the world to publicly fund HPV vaccinations in boys.

The action has resulted in organizations such as the Throat Cancer Foundation to urge the UK to follow suit. However, the Department of Health for England has held its ground, saying that due to the lack of scientific evidence, there was no plan to implement the vaccination of boys into the NHS programme.

According to the Throat Cancer Foundation, the vaccine costs as little as £45 per person, and treatment for throat cancer costs the NHS around £45,000 per patient, meaning there is considerable cause for discussion of the topic.

Taken from Practice Nursing, published 18 Feb 2013.