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Winter Warning: Managing risk in health and care this winter

Earlier this year the NHS experienced what many consider to be one of the toughest winters on record. Twelve-hour trolley waits in A&E departments and ambulance diverts increased. Performance against the 95% four-hour A&E wait target deteriorated. Many parts of the NHS operated for a number of weeks with unsafe levels of bed occupancy.

Critically, this translated into increased risk for patients as the whole health and care system struggled to cope under sustained pressure. A few local systems were unable to cope with this pressure for short periods of time as demand overwhelmed the available capacity. The NHS as a whole coped, but only just. This was mainly due to the extraordinary but unsustainable levels of discretionary effort from staff who reported themselves as having to shoulder an increasingly unacceptable burden.

Underlying this increasing risk is a simple truth. Current NHS capacity, which is largely static, cannot keep up with the continued growth in demand for services from a population whose profile is ageing and where the growth in patients with multiple co-morbidities creates greater patient acuity.

The NHS experienced record demand last winter. It also treated a record number of patients. But, in too many places demand overwhelmed capacity. Although the media focus was on hospitals, there was insufficient capacity right the way across local systems – in acute hospital, mental health, community and ambulance trusts, but also in primary and social care. A particular problem last winter was the rapid growth in delayed transfers of care (DTOCs) due to inadequate capacity in social care.

As soon as last winter finished, there were immediate demands for the NHS to learn lessons and to manage this growing risk more effectively. Although there are early signs from a small number of new care model vanguards that the growth in emergency demand can be flattened, there is every prospect that, over the next 12 months, demand will continue to rise. Growing workforce shortages and lower levels of funding increases threaten the NHS’
ability to match the capacity it provided last year. Some local systems are already reporting that the need for increased savings in 2017/18 is threatening much needed out of hospital and community capacity.

Planning for next winter
The government’s response has been to use the £1bn of extra 2017/18 social care funding announced in the March 2017 budget to try to reduce NHS social care related DTOCs and thereby free up 2,000-3,000 extra NHS beds.

Local authority budgets, which include provision for social care, have been cut by £18bn in real terms since 2010. They understandably argue that they are the best arbiters of how this extra investment should be spent. Faced with the need to ensure the investment was spent  in time, the government agreed that the extra 2017/18 social care investment could be spent in three ways:

●● to support adult social care
●● to support the NHS through delayed transfers of care
●● to stabilise the social care market.

From the NHS perspective, this carries a risk of trying to spend the same £1bn twice, to get both a social care and an NHS benefit, and that the additional required NHS capacity cannot therefore be guaranteed. Now that local authorities are finalising how their extra social care funding will be spent, we can start to see how well and consistently government plans will work.