It’s that time of the year when the first murmurings of winter crisis emerge in the NHS. The PM invited the top brass to Downing Street to thrash out the latest plan to avert the forthcoming crisis.
Last winter, it was the Coffey plan. Her ‘laser-like’ focus on the problems would solve the inevitable rise in admissions. The plan involved increasing 999 call handlers, adding 7,000 hospital beds, providing an extra £500m for social care discharges and creating a £15m overseas recruitment fund.
Did the plan work? Well, thousands were exposed to severe waits for an ambulance. In London, heart attack and stroke sufferers waited more than three hours for an ambulance. At the Royal Free Hospital, patients waited 27 hours for a bed. By December, the plan evolved – thousands of volunteers would emerge. What they were supposed to do to stem the tide of winter emergencies remains a mystery.
NHS England’s data on Bed Availability and Occupancy show the number of beds is up by 761 from the same period in 2022. Between April and June 2023, 103,818 General and acute beds were available at an average occupancy of 90.6%. The Coffey plan led to an extra 1,486 beds available mid-winter – only 21% of what was promised.
By February, NHS England was in on the act with its two-year delivery plan for recovering urgent and emergency services: 5,000 new beds and 800 new ambulances were promised. The discharge fund was rebranded into ‘Care transfer hubs’ with new services, including virtual wards. According to the PM, this year, the plan has evolved. It’s even earlier than ever: more beds, ambulances and discharge lounges, and 15 million more GP appointments.
But GP workforce data from May this year show there are 27,200 fully qualified GPs in England. Down by 427 compared with 2022 and 2,337 compared with 2016. GP numbers are shrinking at a time when record numbers of patients need seeing and treating. Consequently, something has to give – 30% of patients are waiting more than a week to see their GP.
Therefore, we are on safe ground when we say general practice won’t contribute to solving the winter crises this year. Particularly given they won’t receive a penny from the £200m pot supposed to ease winter pressures.
So what about the 800 new ambulances, we hear you ask. Another let down as freedom of information responses from eight of 11 trusts in England revealed orders have been placed for 655 replacement ambulances from 2023 to 2025; however, only 51 will be new.
Furthermore, as we enter winter, there’s a record 7.7 million on the NHS waiting list. 390,000 have waited at least a year for treatment – just the sort of patients likely to be admitted if they pick up a nasty winter bug.
Increasingly, the NHS is left reacting to problems as they emerge. It cannot be proactive; the current strikes will only add to the waiting lists. By winter, we’ll likely cross the eight million threshold as it continues to trend upwards.
Even more troubling is the lack of beds, which is fuelling a rationing of care. An analysis by the Health Foundation showed that 800,000 fewer patients in England were admitted in 2022 compared with 2019. The analysis suggests hospitals are raising their admission thresholds and so admitting fewer patients. More concerning is that reductions were greatest in deprived areas with the most significant health needs.
The level of bed occupancy considered safe is 85%. Yet year-round occupancy remains above these levels. This is no trivial matter. It is not just an inconvenience; it can prove deadly. Estimates based on NHS data suggest a five percentage point increase in bed occupancy is associated with a 1.1% increase in overall mortality.
Central to the problem for the last two decades is the NHS lacks staff and beds. An additional 46,300 full-time doctors would be required to bring us up to the EU average of 3.7 doctors per 1,000 people. Also, there are substantial regional disparities to deal with: the Midlands has 3.5 million more people than the North West, but 4,000 fewer doctors.
The average number of beds in the EU is five per 1,000 people; in the U.K., it is just 2.4. Oh, and what about Germany, where the number is more than threefold higher? In its system, no central minister decides how resources are allocated. Now, there’s an idea. In its federal system, most of the decisions are taken at the state level, and when it comes to health services, there is also competition. Yet, the Government picks up the tab. As a result, no Nightingale hospitals were built, no unsafe Covid discharges occurred into care homes, and there’s little to discuss regarding a winter crises.
The vacancies in the NHS further exacerbate the situation. As of June, there were 125,572 vacancies in secondary care in England. Nearly 10.6% of all nursing posts are unfilled. Inevitably, those remaining in post are required to do more with less.
The shortages produce high-stress environments with high turnover of staff and absences. Anxiety/stress/depression/other psychiatric illnesses were the most reported reason for sickness in the NHS, accounting for one in four of all sickness absences in April and over 472,500 full-time equivalent days lost.
What matters is accountability; who should be responsible? If a doctor makes a mistake, you can turn to the GMC to hold that practitioner accountable. But when it comes to the NHS, who should take the blame? Thérèse is not about anymore to ‘fess up to her shortcomings: she lasted all of 48 days in office, the shortest-serving Health Secretary in history. Simply replacing one minister with the next does nothing to solve the systemic problems facing the NHS. Indeed, all it seems to do is lead to regurgitation of the same plan with a bit of window dressing.
The population over 65 has grown by 2.4% in a decade and is much sicker – short-term fixes won’t prevent the recurring crises. Instead of money-throwing and an unclear chain of accountability, it is time for a proper, independent, well-funded study to identify the drivers of this recurring and complex situation and the start of some long-term plans to address the situation.
Central to the problem is the shortage of beds. We could look to our European neighbours to assess what is and isn’t working and determine the safe minimum level of beds and occupancy per head of population required. But we remain resistant to learning how others do it – hence, the troubles persist.
Enough taxpayers’ money has been wasted or stolen in the last few years. We now need answers to care for our people.
Dr. Carl Heneghan is the Oxford Professor of Evidence Based Medicine and Dr. Tom Jefferson is an epidemiologist based in Rome who works with Professor Heneghan on the Cochrane Collaboration. This article was first published on their Substack, Trust The Evidence, which you can subscribe to here.