Extra funds set to relieve pressure on staff this winter

The NHS could not be better prepared for winter. At least that was the message when the Department of Health, NHS England and Public Health England launched their Stay Well This Winter campaign.

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With the national flu vaccination programme being extended to even more children this year, and winter money given earlier than ever, the national bodies presented an upbeat message, praising the ‘strengthened planning’ that had taken place.

In theory, they are right. For the first time winter money – about £400m of it – was included in the baseline allocation for the health service, meaning it has been in the system since April.

What is more, councils are being allowed to use some of the money earmarked for the now-delayed care cap to boost the numbers of home-care services and reduce delays in hospital discharge.

Meanwhile, through the work of the Urgent and Emergency Care Review and Vanguards programmes, more long-term solutions are filtering through from ambulances being able to share real-time patient information with emergency departments (EDs) to increased access to GPs and greater integration with the NHS 111 system.

NHS England national director for acute care Keith Willett believes the initiatives will help steer people to the right place ‘whether it’s pharmacies, NHS Choices, NHS 111 or A&E’.

Vacancy rates

After a summer of little respite, however, there are doubts about how the system will cope. In England the target has been missed in May, June and August, while Scotland, Wales and Northern Ireland have been struggling too.

‘It looks like it will be an extremely difficult winter again,’ says Royal College of Nursing Emergency Care Association chair Janet Youd. ‘The pressures are as great as they were this time last year.

‘One of the big problems is that we can’t attract staff. Emergency departments used to be the place where people wanted to work, but like the rest of the system we have a real problem with vacancy rates. Pay has been squeezed and so nurses know they can earn more doing agency work.’

Indeed, this was one of the key themes of the Care Quality Commission’s (CQC) State of Care report published in October.

The report incorporated the first full year of the new ‘tougher’ Ofsted-style inspection regime brought in by the CQC and included information on 79 hospital trusts – just under half of the total in England. It warned that safety was a ‘significant concern’, with nursing staff shortages highlighted as a major cause.

The problems tended to be greater in EDs than other parts of the hospital. Some 9% of urgent and emergency services were rated ‘inadequate’ with another 49% ‘requiring improvement’. Only general medical care performed worse out of the eight areas of hospital care highlighted in the report.

It said inspectors were ‘surprised at just how very poor’ some of the worst care was, citing how A&E patients had been ‘kept on trolleys overnight in a portable unit without proper nursing assessments’ at one hospital.

Although the results must be seen in context, many of the sites the CQC has targeted first have been the ones they had most concerns about to start with.

Nonetheless, Ms Youd believes the findings, coupled with the growing levels of deficits among hospital trusts, show the NHS is being caught between a rock and a hard place.

‘It puts us in an impossible position. If we try to save money we risk safety. It’s not just an ED problem. We are seeing it in other parts of the system like intensive care too. The financial problems are hitting education and training budgets too. It means in terms of skills and experience there is a shortage as well.’

RCN professional lead for acute, emergency and critical care Anna Crossley agrees. She says that further pressures on ‘every part of the hospital, starting with EDs’ are ‘highly likely’ this winter.

She believes staff shortages are just one part of the problem. ‘The anticipated increase in emergency admissions requires an increase in hospital flow support and space which can to some extent be planned for – the problem is that hospitals cannot physically expand to accommodate more beds needed, and the pressure on every area of the hospital increases.’

Even if this could be achieved, she says, it would not solve the problem. There also needs to be ‘equivalent services in the community with seven-day services to provide physical and mental health care’.

‘The root of all of this is the need for increased funding,’ she adds.

NHS Confederation chief executive Rob Webster believes the pressure on the system proves there needs to be a re-think on how the health service is viewed.

He says ED performance is a function of community support, social care and the local people ‘as much as hospital staffing’.

‘We need a fundamental shift in the way we regulate care. We’ve seen some progress, but more is needed.’

Rising demand

Will this work? After all, each winter the government talks about how it is encouraging people to use EDs responsibly. Yet each winter demand rises.

Royal College of Emergency Medicine president Cliff Mann has his doubts. ‘A&E is a trusted brand. You can tell people they shouldn’t go, but that just makes them more likely to want to go.

‘They know what they will get: quick access to high-quality care. So instead we need to start thinking about emergency departments as just one part of the A&E brand alongside GP services, mental health and dentistry. This requires more co-location of services to make sure that those patients who turn up but do not need emergency care can be seen by other staff.

‘Yet fewer than half of hospitals have co-located some services, and none have all of these. If we did this, we could make sure EDs were free to concentrate on the patients that really needed that care.’

Find out more

Copies of the state of care report are available at

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