Society for Acute Medicine – winter briefing 2019/20

This winter could be the toughest yet for both patients and staff in the NHS and funding pledges in the Queen’s Speech will do little to allay the concerns of staff and patients about the ability of hospitals up and down the country to cope.

Any promises or commitments of investment are most certainlly not a cause for celebration, they are simply a necessity the government cannot ignore. Sadly we cannot make up for years in a matter of months, which is what would be needed to get us through the winter period safely.

As late as yesterday (18 December), a Parliamentary briefing paper has laid the statistics bare, quoting that in 2010 only one in 25 people who attended our emergency departments (EDs) were there for over four hours but this year it is one in five who spend more than that time target.

Performance has dropped month-on-month with no major unit achieving the ‘target’ in November 2019 – and fully expected to get worse as winter starts to bite.

The reasons for this are well known and the Society for Acute Medicine, among others, has been warning of the impact for over 18 months now but feel that this has been in vain due to the political vacuum and the ‘Westminster bubble’ focusing on one thing only, Brexit, at the cost of any other issue.

We have released many statements and reports highlighting this and, in recent months, have written twice to the Secretary of State for Health without engagement from him personally in any response. We would be willing to meet Mr Hancock at any time to further discuss our concerns in a constructive manner.

The really significant issues are the ever-rising demand that has not in any way been matched by resource in estates, equipment or staff. The well-known deficiencies in community and social care are heaping further pressure on the acute sector and are now matched by the impact of the so-called ‘pension tax crisis’ that has seen senior workers in the NHS effectively financially punished for trying to go the ‘extra mile’ needed each and every day.

With regards to demand, yesterday’s Commons’ paper showed the rise from 2010 to 2019 in attendances at ED was 15% and in admissions via ED 35%. We also know from the NHS performance statistics that these have risen by probably 3% to 4% in the last year since these figures were prepared. This is in the context of a 10% drop in overnight beds over the same timeframe following much steeper declines in the preceding 20 years. There is no room left for manouevre.

To focus on the pension ‘issue’, this has been a problem building since its ill-conceived introduction in 2016 but it is hitting hard this year and, unless anything substantive is done, the impact will rise year-on-year. It has seen clinicians cutting back on activity, initially to a standard 40-hour contract but now to less in efforts to avoid five-figure tax bills on what is generally income that might not actually be gained as a pension for 10 to 20 years.

This is impacting across the board in clinical and non-clinical areas as described by NHS Providers in a paper released yesterday. For winter it means that trusts will not be able to rely on clinicians picking up extra shifts at weekends and evenings. The response to this is mixed, with the latest ‘quick fix’ being greeted with a degree of scepticism and trusts all interpreting other measures in a very mixed fashion, for example, with the ‘recycling’ of contributions suggested by NHS England being ignored as it was not an absolute mandate and offering ‘solutions’ that only apply to small numbers of those affected (suggestions including some form of help for those with ‘responsibility payments’ or clinical excellence awards).

The Department of Health and Social Care confirmed yesterday it would “carry out an urgent review of the pensions annual allowance taper” to report at the Budget.

So, what can – and should – be done?

We welcome the promise of funding but we feel very wary – with good reason. Figures suggest there is a growing backlog in essential maintenance now estimated at £6.5 billion with £1.1 billion needed for ‘high-risk’ repairs.

We also need some assurance of how and where any finance may be used for the greatest benefit in the most expedient timeframes. The SoS has made very clear his focus is on IT and whole genome testing, but they don’t provide the solutions we need right now.

The IT fixation is particularly problematic given that many NHS units have not progressed beyond Windows 7 and host computers that take 10 minutes or more to start up, with a myriad of different log in procedures and no inter- connectivity.
For senior staff the obvious fix is to not only review the position on pension taxation but to act and act swiftly to have formal plans in place for the next tax year starting April 2020.

For junior staff we need to recognise and reward their working conditions, place more emphasis on a ‘learn not blame culture’ and continue to make medicine an attractive and fulfilling career.

We have a long-term plan for the NHS but still wait for any such declaration for social and community care and, while there is a lot of good intention in the plan, there must be some caution regarding the possibilities.

The main plank for reducing bed pressure is the use of Same Day Emergency Care (SDEC) – AKA ambulatory emergency care – with notable ambitions in this area. The measurement of this is hampered by not actually having a definition of what an ‘open’ unit actually is, allowing many trusts to claim they have a service that is actually nothing of the sort in terms of provision.

Also, there is immense pressure on these areas, most frequently co-located with acute medical units, and data has shown that up to 45% of these units being hampered by being used as ‘overflow’ wards for inpatients. They are frequently seen as easy targets by hard-pressed managers in times of almost constant system stress.

We fear the NHS will never be able to fully implement SDEC fully as desired.

One example of the impact of this can be seen in the recent NCEPOD review of the treatment of pulmonary embolism (blood clots which travel to the lungs) which, in many cases, can be performed through SDEC but, alarmingly, it is often only a 9am to 5pm, Monday to Friday service. More than 10% of the patients included in the NCEPOD review either died from the problem or needed treatment in intensive care.

The NHS is looking at new ways of measuring targets for many areas, including emergency care, but there are growing calls for more openness in this process and concerns that the new suggestions will actually negatively impact on care for the those needing inpatient beds when the focus to meet the target might be on the numerically higher number of those who do not need admitting.

Lastly, but probably most importantly, we need to urgently support our staff throughout the NHS as they are reaching the stage of utter exhaustion after more than two years of unrelenting and increasing stress and workload while under ever-increasing scrutiny and pressure from trusts trying to balance the financial books by every trick in the book regardless of the impact these ‘measures’ will have on the intangible and immeasurable areas such as morale (a new app is not the answer!).

To summarise, the NHS is under the most pressure it has ever seen and quite how we will get through the next few weeks and months remains to be seen.

We ask all those in central positions to engage with those who actually work on the frontline up and down the country to put out realistic messages of how things are and not hide the reality in endless positive spin that no-one working in the NHS believes.

We must, above all, work together to ensure all those people who need help receive it in a safe, dignified and caring manner while protecting the wellbeing of the staff on whom we all depend.

Dr Susan Crossland, President

Dr Nick Scriven, Immediate Past President