Winter is Coming

Does the NHS have enough beds to cope with the pressures of winter? Simon Stevens, the chief executive of NHS England says the NHS has ‘six to eight weeks to prepare’ and that the flu season could be bad given the H3 strain outbreaks in the antipodes that are heading our way. Simon says there are up to 3,000 NHS beds that could be freed if social care had the capacity to take patients that no longer need to be in hospital (so-called Delayed Transfers of Care DTOC). And yet NHS Improvement has warned that £1 billion extra investment in social care has failed to reduce DTOCs, and council leaders have written to Jeremy Hunt to say their DTOC targets are ‘undeliverable’.

This seasonal crisis comes on top of the everyday crisis of finding beds for patients in the NHS. The 2014 OECD league tables show that the UK, at 2.8 beds per 1000 people, has amongst the lowest for the number of hospital beds relative to population size, with England pretty much at the bottom. In the last decade, more than one quarter of hospital beds have been closed, with 37,000 fewer general and acute beds now than in 2006/7. Long stay NHS beds fell off the NHS under Margaret Thatcher, and with care homes closing every week due to debt and poor care, there simply isn’t the capacity in hospital or the community to cope with the demands of an ageing population. The UK’s hospitals are already among the fullest in the OECD, with occupancy above 90% and knock on effects for safety.

Stevens fails to mention that the situation may well get worse with the bed closures planned in the 44 Sustainability and Transformation Partnerships (STPs). Many of these have yet to be fully published and publically scrutinised, despite strong campaigning from groups like 38 Degrees, which makes a mockery of the government’s previous ‘no decision about me without me’ pledge. Jeremy Corbyn claims that STPs will cut a third of hospital beds, based on a sample of STPs brave enough to put figures on their plans. In Derbyshire, 535 of 1,771 beds will be cut by 2020-21 (30%). West, North and East Cumbria plans to reduce beds in cottage hospitals from 133 to 104, with beds at Cumberland Infirmary and West Cumberland Hospital going from 600 to 500 (an 18% cut).

A survey of England’s Clinical Commissioning Group chairs and accountable officers by the Health Service Journal last October was more revealing. Of the service changes planned or likely under STPs, 52% were closing or downgrading community hospitals, 46% predicted a further reduction in inpatient beds, 31% panned closures or downgrading of a full A&E service, 30% were planning closing an urgent care centre, 23% planned reductions in staff in acute services, 23% were stopping inpatient paediatrics in 1 or more hospitals and 21% were planning stopping consultant led maternity services in 1 or more hospitals. If these changes are a rational centralisation of expertise into bigger centres with better outcomes, fine. But the suspicion is that many changes are being enforced to make £22 billion savings rather than improve the quality of care, which is why the plans need full scrutiny.

Many of the same CCG leaders weren’t confident their STPs would deliver, citing lack of funding, political opposition, staff opposition, public opposition and inability to control the demand for NHS services as likely barriers. The theory that some hospital admissions could be prevented by better care in the community is sound, but it requires substantial investment in community services. Cutting hospital beds further to fund that investment is likely to backfire. Many patients who require hospital care are too sick to be treated in the community. Analysis of the spike in deaths in 2015 published in the British Journal of Healthcare Management suggested that a rise in various infectious agents, both viral and bacterial, was a more likely trigger for death than austerity. Some patients will have died anyway, but lack of capacity in the NHS means that far too many are getting poor quality care, particularly towards the end of life. Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, has analysed the section 28 reports of the chief coroner, who is obliged to report on deaths where there is a risk of other deaths occurring in similar circumstances. The reports suggest a significant decline in ambulance safety over recent years, particularly due to slow handovers in overcrowded A&Es preventing treatment and tying up the ambulance crew. There were also 48 warnings about the ability of ambulance services to handle the volume of calls and respond appropriately. Simon Stevens is right to warn of the perils of the seasonal H3 flu strain. But the strain on an overfull NHS and social care system is year-round, and patients and staff are harmed each day