The NHS is on the brink of a major, messy failure. If nothing is done to address the underlying issues now, the failure will be deep with grave consequences and a long recovery. This winter things are set to go catastrophically wrong.
Pressure on health services normally reduces in summer, often producing undue optimism about how they will cope come winter and delaying necessary preparations. Last summer there was virtually no reduction in pressure. Oddly, this failed to dent the optimism. The revised story was that unrelenting pressure had become a year-round phenomenon, so increased numbers and longer waits were now normal and the coming winter wouldn’t be any worse.
Unfortunately it was, the worst in 20 years. Demand for healthcare had simply reached a new (summer) plateau, with new peaks of winter demand inevitable and predictable – but not predicted and not prepared for. Waits and delays soared, even though demand increased modestly, following a well-established trend.
The crisis happened because the NHS starved itself of the capacity it needed, in the futile belief that lack of supply would constrain demand and so save money. This led not only to running out of spare capacity, but to shortages and the loss of the elasticity to cope with new peaks in demand. The result was waits and delays multiplied rather than increased, and it contributed to the worst NHS deficit in a decade.
Despite this, the lesson has not been learned that the NHS’s struggles this summer foreshadow a meltdown this winter.
Some 90% of trusts are predicting a deficit this year. The deficits add up to £2bn, double last year’s figure. Performance continues to wallow, with little or no recovery from the long delays and extended waiting times of last winter. Crucially, performance this summer was worse than last summer, which prefigured last winter’s crisis. The obvious conclusion is that it prefigures something worse.
The picture that emerges from those overseeing the system is consistent and depressing. They feel overwhelmed. The task is too big, too various, undo-able. No one is in charge. Things are perceived to be getting worse, despite their best efforts.
The stress and financial pressure on social care is reducing the capacity in NHS hospitals by up to 25% by delaying the placement of patients who need social care but no longer need hospital care.
The move to 24/7 working and the Care Quality Commission’s insistence on higher staffing levels and standards are also making the task of delivering quality care with the money available more difficult, as the BMA recently highlighted. Trusts are unable to price in the increasing costs of meeting these demands and are left in a catch-22 situation: skimp on the required investments, or spend money you don’t have to make them.
Partly because the buck stops with the trust delivering the care, rather than the blame at least in part being put on a flawed system in which the CQC and commissioners can put unreasonable demands on trusts, paralysis is created and problems are left unresolved, bringing the NHS to the brink of failure.
So, not only do the causes of last winter’s crisis remain, they are worse than a year ago. There is virtually no slack, obvious potential capacity shortfalls, and little investment in addressing them. There is insufficient money, and not enough trained staff to employ even if the money was there. Peaks of demand, higher this winter than last, will exert extra pressure on services already at full stretch.
There won’t simply be a repetition of last year’s crisis, because the scope for lengthening waits and delays has been largely exhausted. The system won’t cope, meaning either standards will fall, or some people won’t get treatment. As this becomes apparent, there will be national outrage.
- Jan Filochowski spent 20 years as an NHS chief executive of six large hospital trusts, lastly Great Ormond Street, before retiring from the health service at the end of 2013
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