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'Late lies the wintry sun a-bed,
A frosty, fiery sleepy-head;
Blinks but an hour or two; and then,
A blood-red orange, sets again.'
Stevenson.
Over the weekend Two-Clocks-Cooper made much of the NHS ‘rolling out our winter plan.’
Let’s have a look… because, Cooper’s reassurance about the NHS winter plan deserve, an up-close look.
The good news is... there are sensible preparations and useful investments.
The question is... whether they add up to enough capacity, in the right places, with enough people to deliver it.
NHSE’s winter instructions went out in July. Draft local-plans were due in August, stress tests in September and board approval by the end of that month.
That timetable deserves a lot of credit. Early preparation gives services a chance to identify weaknesses and do something about them.
By now, we should be able to see what those preparations have nailed in. The priorities are familiar and reasonable;
- more urgent care outside hospital,
- vaccination,
- mental health crisis support,
- safer discharge and
- better ambulance handovers.
The plan also expects hospitals to tackle corridor care while maintaining planned treatment...
... this is tough, bordering on the undoable. They require substantial operational headroom, and...
... dare I mention money? All I see is a black hole that'll need filling?
In September, adult acute beds were 94.9% occupied. Each day, 13,647 patients medically fit for discharge remained in hospital.
That leaves little room for a surge in admissions, infection outbreaks, beds closed for isolation or medical patients overspilling into elective surgical beds.
The plan recognises discharge. Its credibility depends on the detail;
- how many additional home-care packages,
- rehabilitation places and community nursing visits are actually commissioned?
- When do they start?
- Who provides them at weekends and over Christmas?
Where is social care in all this? Dunno...
Hospital processes are not exactly Caesar's wife when it comes to creating system-flow.
Delayed decisions, medicines, transport and assessments need attention. Councils can't be made responsible for every blockage, but asking partners to collaborate needs to produce a service and a plan we can rely on.
Sunday’s announcement offered almost £140 million for 14 urgent-care schemes.
Separately, 25 new or expanded sites announced in April are due to open for winter.
Read carefully… the £-release does not establish that all 14 newly announced schemes will be operational this winter, neither explain their staffing and running costs, nor…
- the opening dates,
- funded rotas,
- operating hours and
- expected additional activity.
Only then we can judge how much pressure they might absorb.
As we see in this morning's news; the Royal College of Emergency Medicine's survey describes A&E pressures (92%) high or very high and 88% reporting they are under greater pressure this year, than a year ago.
Ian Higginson the President of the RCEM says;
"Overcrowding, corridor care, the impending surge of demand from winter, and lack of meaningful preparations, are creating perfect conditions for a terrible winter...
... we are not managing now and we simply are not ready for winter."
There’s another tension...
... the wider NHS planning framework seeks a 30% reduction in agency use and a 10% annual reduction in bank-staffing expenditure.
Savings through better permanent staffing are welcome, but the upshot of that is; winter plans need to show how services will cover sickness, vacancies and unexpected demand within those constraints.
Vaccination belongs in that calculation.
The NMC has encouraged flu vaccination
The GMC advises immunisation
against common serious
communicable diseases unless contraindicated.
Thanks for nothing.
Call me old-fashioned but as a patient with a suppressed-immune-system, I'd like not to have to worry about catching something from the people looking after me.
Trusts already make vaccination accessible and support informed decisions.
Despite an improvement last winter, fewer than half of frontline staff in England appear to be vaccinated.
Staff protection is part of keeping promised capacity available.
Ambulance handovers are another test.
The winter instructions aim for 15 minutes, with none exceeding 45. Faster handovers should release crews to answer calls, but …
… improvement must extend through the hospital;
- patients need timely assessment,
- treatment and
- an appropriate place to receive care.
Otherwise, the risk is that the queue simply moves indoors.
The promise to protect planned treatment also deserves scrutiny.
When emergency demand exceeds capacity, what protects operating lists, recovery areas and their staff?
Dunno.
Which services are genuinely protected, and what happens when the assumptions fail?
Dunno.
The demand assumptions should be published.
How severe a flu season has each area planned for? What allowance is made for staff absence and infection-related bed closures occurring together?
A plan that works only when each service performs as hoped offers little reassurance when several parts of the system come under pressure at the same time.
These are questions the September stress tests should have explored.
Did they?
Dunno.
And, at the same time, keeping up with waiting list targets? I have a question...
... isn't there an obvious hole in NHS finances? I don't see how all this can be achieved without an injection of cash?
Publishing the gaps, the action taken and the risks still unresolved would create a font of knowledge to share and compare.
I’d judge progress like everyone else would;
- fewer prolonged waits,
- less corridor care,
- safer discharge and
- fewer elective cancellations,
- alongside ambulance performance.
To borrow from Mike Tyson; everybody has a fight plan 'till they're punched in the face...
... everybody in the NHS has a winter plan until winter lands the first punch.
The question for Yvette Cooper is whether the NHS has the pounds, people, beds and community support...
... to stay on its feet.
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