Report

Under pressure: NHS priorities this winter

How the government and national bodies can ease pressures on the frontline this winter.
Ilse Bosch

11 November 2021

Key points

  • Ahead of the release of the monthly NHS performance statistics, we surveyed NHS leaders to seek their views on current pressures on the front line, where pressures lie and what measures the government and its national bodies could introduce now to help.
  • Nine in ten NHS leaders say that current demands on their organisation are unsustainable, with just under nine in ten saying that a lack of staffing in the NHS as a whole is putting patient safety and care at risk.
  • Leaders called for the government and national bodies to deliver more support for social care to ensure effective discharge arrangements are in place. They have also requested clearer messaging to the public about how difficult this winter is likely to be.
  • We have gathered some examples of how staff across the system are working together to deliver more care under difficult circumstances.
  • During the next few months the NHS will, to the best of its ability, continue to treat patients with the most urgent need and continue its commitment to deliver the highest possible quality service across the system. To achieve this, the health service needs four key actions in return:
    • honesty from political leaders.
    • boosting the booster programme.
    • letting local leaders lead
    • bolstering the social care sector.
  • We are asking political leaders to support and communicate public-facing messages on how the public can support the NHS, including the single most important step of getting vaccinated.

Introduction

On 11 November, NHS England and NHS Improvement published the monthly performance statistics for the health service in October, describing what is being delivered and what the demand for care looks like across the system.

In line with previous months’ reporting, the figures show that the NHS continues to be under severe pressure as it heads into winter, with record demand on urgent and emergency care, increasing elective referrals and rising bed occupancy rates. Beds are also being filled by medically fit patients who cannot be discharged because there are no domiciliary or care home places available for them. This is on top of mounting pressure on mental health services, community services, primary care and large increases in ambulance handover delays.

We have also published a summary and analysis of this data. 

What does the service say?

In advance of the release of these figures, we surveyed NHS leaders to seek their views on what pressures feels like on the front line, where the pressures are, and what measures the government and its national bodies could introduce now to help. Our key findings, based on over 400 responses, found the following:

One primary care leader said:

“The NHS as a whole is under a pressure never before witnessed by this generation of clinicians. The gate keepers of this demand are general practice and unless this primary care crisis is addressed, the rest of the system will be destined to fail.” 

A trust chief executive said:

“Systems are at breaking point and risk is unacceptably high (for) some cohorts of patients, be that in emergency, primary care, cancer or elective care (or elsewhere) but where is the honesty and openness about this?” 

The NHS's continued commitment

The NHS is committed to working with the rest of the system to bring down waiting times for patients who are in line for elective care. This is ambitious and means the service working harder than ever, delivering around 30 per cent more by 2024/25 compared to pre-pandemic levels. This pledge starts now but will stretch the NHS during its busiest time: winter.

As ever, during the next few months the NHS will, to the best of its ability, treat patients with the most urgent need. It will also continue its commitment to deliver the highest possible quality service across the system, including in at the front door of the NHS - primary care - where more patients are being seen than before the pandemic, as well as mental health and community services.

It will work as a system and support staff who are exhausted and depleted, having already experienced a period of extreme pressure and given so much to the people they care for.

Amid the unrelenting pressures, staff are working harder than ever to support patients and serve local communities:

  • Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) set up a successful initiative to extend elective care to 1,000 more patients between May and September. The Scalpel Project was delivered by the trust’s general surgery division and focused on seeing patients that had been waiting longest.

    Through a special series of six Saturday clinics, they were able to provide flexibility to patients who are unable to attend a weekday appointment. The trust is now looking to build on this project, to embed the positives of the initiative into the system and share best practice with others across the country facing similar challenges.

    Read more on the BHRUT website.

  • At the start of the pandemic, Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) started monitoring patients remotely to free up capacity for COVID-19 patients. This ‘virtual ward’ offers 24/7 monitoring of vitals such as respiration and oxygen saturation, with nurses, doctors, pharmacists and a range of other professions providing full care and support that would ordinarily be held within a physical bed in hospital. The trust also developed virtual wards for other pathways, including palliative care, cancer patients, those on the gastroenterology pathway and now those awaiting treatment or diagnostics.

    Feedback from patients has been overwhelmingly positive and staff have benefited from more flexibility. Plus, unlike traditional wards, the service can more easily flex the numbers it cares for, often without too much impact on staffing needs. This shift to virtual wards freed up 3,548 day beds, improved efficiency and patient care, and virtual monitoring at home proved to be 82 per cent cheaper than having someone in an acute bed.

    Find out more on the NNUH website.

  • GP practices in Barking and Dagenham are working smarter to understand what patients need and deliver their services more effectively. All Together Better, Barking and Dagenham GP Federation has been working with seven GP practices in the patch to build a better picture of patient need and recommend ways to help manage demand. They collected front-door activity over 44 days and found that just under 60 per cent was administrative enabled, which meant that by changing how they worked, including recruiting additional medical secretaries and increasing resources such as FAQs, they were able to better support administrative workloads.

    The federation also recommended recruiting pharmacy technicians to support with medicine queries after finding that medication queries took up 20 per cent of front-door activity. The federation is working to expand this project to support more practices locally.

  • The urgent community response team (UCRT) in mid and south Essex responds to the crisis needs of people in their own homes to avoid admission to hospital. A range of specialists have started to work together to support people to stay in their own homes when experiencing an acute medical crisis, such as an infection or fall, and support for those needing urgent support for long-term conditions.

    Focused on what patients in the community needed, three community organisations are collaborating to offer a single service, resulting in more people being able to access care and fewer people needing emergency care or local ambulance services. The team has done an initial case review looking at emergency department avoidance, to support the hospital trusts in planning their bed requirements.

    Find out more on the Mid and South Essex Healthcare Partnership’s website.

  • In 2018, the City Care Health Partnership CIC, a social enterprise providing health and care services, established the Jean Bishop Integrated Care Centre, which is transforming care by providing out-of-hospital care and enabling residents to stay in their own homes. In 2020, the partnership established a frailty response line for health professionals, social care and care homes to call if they are worried about a frail and elderly patient, ensuring care is provided at the right time and subsequently reducing the need for attendance at hospital or emergency departments.

    The team of health, social care and voluntary sector professionals work collaboratively to provide a holistic approach to supporting people and ultimately improve health outcomes. ​The centre’s work has helped to reduce pressure on other acute and social care services in Hull, achieving a sustained reduction in unnecessary emergency department attendances and hospital admissions as well as GP appointments.

    Find out more about the Jean Bishop Integrated Care Centre and the frailty support line.

  • Teams are working across sectors to ensure people are able leave hospital as soon as possible after their acute care is complete. New discharge-to-assess approaches have allowed acute trusts to innovate using new funding to free up acute beds during COVID-19, as well as provide much-needed support to stretched social care providers and support more people to live well at home. 

    Before the pandemic, 20 to 30 per cent of NHS acute beds were consistently occupied by patients who were ready to leave hospital but were awaiting confirmation of a care package or transfer to a community or care home bed. Discharge to assess involves local independent sector and social care partners working with acute trusts to enable patients to leave hospital as soon as they are medically ready, crucially freeing up capacity in acute settings.

    Sussex Community NHS Foundation Trust reported that the average length of stay fell by 37 per cent during the COVID-19 response as a direct result of discharge to assess. Across the NHS, 30,000 beds were freed up during the first COVID-19 wave, as well as 6,000 staff including 4,000 frontline nurses. Between winter 2019/20 and winter 2020/21 we saw a 28 per cent reduction in patients staying more than 21 days.

    Find out more in this briefing from the Community Network.

  • Partners across the south coast worked together to provide a single point of access to mental health crisis support and reduce the need for patients to use emergency services. NHS Hampshire, Southampton and Isle of Wight CCG and Portsmouth CCG worked with partners, including people with lived experience, to develop a seamless, all age, single point of access to mental health nurses working in NHS 111. As well as providing easy access to support for patients, this approach has relieved pressure from the rest of the system by reducing attendance at A&E and other urgent and emergency services. Since the service began, it has reduced the number of patients referred to primary care from 69 per cent to just 10 per cent. Mental health contacts to 999 have also been reduced by 26 per cent.

    A similar approach to triage services delivered by mental health nurses in Southern Health NHS Foundation Trust showed massive impact on outcomes for patients. 88 per cent of calls are now supported with self-care and home management, compared to 11 per cent before the service was provided by a mental health professional with access to patients’ care or crisis management plans.

    Find out more about the NHS 111 mental health triage team.

  • Partnership working in Doncaster is stepping up support for children and young people’s mental health at a time of rising need. The Social and Emotional Mental Health (SEMH) Group is a multi-agency forum that includes key decision-makers across the Doncaster Children’s Partnership, which represents the CCG, local authority, CAMHS services, police, education, and other partners. The work of the SEMH group accelerated in 2020 in response to the tragic increase in children and young people accessing the emergency department following a suicide attempt or self-harm.

    Through partnership work, the SEMH promotes better joint assessments, planning and service delivery for vulnerable young people in need of care without delay. The CCG’s designated nurse for children’s safeguarding and looked-after children is a key member of this group and can escalate any enduring issues that cannot be resolved as a group. The development of the SEMH group has helped the different agencies understand each other’s pressures and ensure children and young people receive the support they need. The work means children receive the right care at the right time and at a time of high pressure has enabled partners to work smarter rather than harder. 

  • Bolstered by board-level support, Hull University Teaching Hospitals NHS Trust has increased its workforce through apprenticeships and international recruitment, achieving an oversupply of nurses to help current teams fight the pandemic, continue to reduce the backlog of patients waiting for treatment, and be better placed going into winter. Other organisations are using solutions such as employment passports to help staff move between organisations.

    Find out more in this case study from NHS Employers.

What is required from the government and its national bodies

In return for its continued commitment, the NHS needs help to ensure that in addition to meeting the most urgent care needs, it has capacity to start to treat the people who have been waiting the longest for care. This requires four key actions:

1. Honesty from political leaders

Although the Secretary of State has acknowledged potential increases to waiting lists, our survey results show that NHS leaders disagree with his further assessment and argue that pressures are currently ‘unsustainable’. The government needs to level with the public now and clearly articulate the size of the challenge that the NHS is facing and what they can expect this winter. The hard work and value the NHS is delivering needs to be recognised and safeguarded from the top.

  • While additional money is welcome, we all need to be honest that it can’t buy staff who do not exist. The health and care system needs help this winter. It needs to be able to deliver care where it is most needed with the full support of national leaders who are able to accurately articulate the pressures and recognise what is being delivered despite them.

    The NHS is run by people for people. On any other day, a nurse or doctor could be a patient. Honesty and transparency about what the NHS is delivering and can achieve is important to the vital relationship between the two.

    Many staff are exhausted, with wider workforce challenges compounding the situation. High absence rates, due to stress, psychological issues, needing to self-isolate or long COVID, are exacerbating staffing issues that existed before the pandemic. For national leaders not to listen nor endorse the message that they are sending loud and clear is at the very least, disheartening. At worst, it could lead to more and more people leaving the service and exacerbating the struggle to deliver care.

    Leaders must realistically manage the expectations of the people who need care, too. With hospitals full to capacity and demand for primary care above pre-pandemic levels, there are difficult messages to deliver around access or waiting times. These messages are being left to the staff working on the front line, who have to explain a system-wide issue they have little control over. We also ask political leaders to support the asks we have for the public.

2. Boosting the booster programme

As winter months lead to the increased transmission of viruses, easy access and a simple, flexible process to deliver vaccines at scale is our best line of defence. We need a concerted public communications campaign about the impact of not getting vaccinated on them and the wider population. We also need to make it easy for people to access the vaccination and to ensure our information systems are capable of sharing accurate data across the system, - so we know where the gaps remain and in what communities.

National programme leads need to make sure people have a choice of sites and easy access to information that is shared with their local GP - for flu vaccination, COVID-19 boosters and the ‘evergreen’ offer for first and second doses.

  • The exceptional effort seen during the first phase of the vaccination programme saved around 130,000 lives, with almost 95 million doses delivered across the UK. However, we know we are now at a particularly sensitive point in the pandemic, where the natural immunity provided by vaccines is starting to wane, particularly for older adults and those more at risk from COVID-19.

    One of the key measures to reduce the risk of avoidable deaths and cases of severe illness from COVID-19 this winter is to ensure the right people receive their booster vaccination when it is due. Early results from Pfizer shows that a booster dose can increase the protection up to 95.6 per cent against symptomatic infection.

    Although we welcome the recent uptick in bookings to receive the booster, for the NHS to continue to play its part in the rollout and ensure this reaches the right people over the coming months, including those less likely to come forward, the process needs to be as flexible as possible.

    There needs to be clear, consistent public messaging above all, on the impact of not getting vaccinated on them and others. It must be easy for people to access the vaccination and we need to ensure our information systems are capable of sharing accurate data across the system so we know where the gaps remain and in what communities.

    It should be easy for patients to be able to access information on how and when to book their vaccine appointment. This requires effective communication at a local level, as well as improved links between the national and local booking systems. This will help to identify particular gaps in vaccination coverage where people are not being reached and enable better and more targeted engagement to encourage people to come forward.

    Clear communication and involvement with voluntary and community organisations will be particularly important for people with severe mental illness (SMI) who are included in priority group six and may find accessing care more challenging. For instance, we know that people with schizophrenia are almost three times more at risk of dying with COVID-19 than average, however vaccine levels for people with SMI were below the uptake of the general population.

3. Letting local leaders lead

This winter will be about treating the most urgent needs while also tackling waiting lists. Local leaders from the health service, local authorities, social care and wider system who know their service and populations best, who deliver a complex portfolio of risk every day, must be empowered to do so. We call for leaders to be able to act in an agile way and change priorities as required, including postponing elective care without recourse to a national or regional team.

  • With urgent COVID-19 cases necessarily crowding out other types of healthcare over the last two years and some hospitals already operating close to full capacity during the normally quieter summer months, people waiting for outpatient procedures, cancer treatment and pain-relieving surgery have soared. This also creates more demand for care across other areas, including community and primary care. According to the BMA, the number of standard appointments in general practice rose by 4.7 million to 28.6 million since last month.

    Tragically, this has affected people living in the most deprived areas almost twice as much. With the addition of high levels of emergency demand as we head into winter, we need the right people to be able to make the right decisions at the right time.

    That is local leaders across the whole health and care system. They are best placed to manage the complex portfolio of risk that they will face. They know that only around 20 per cent of the elective backlog requires in-patient care, the rest do not need a hospital stay and are well placed to make the decisions that enable the 80 per cent of care to continue to be delivered via outpatient facilities.

    For instance, when acute leaders say they need to suspend elective activity they will have done so with a full understanding of the competing risks from COVID-19, urgent care, elective planning, quality and workforce planning. They know their populations and what is required to tackle health inequalities at the same time as delivering care. They need to be empowered to make the right decisions, and if and when they say they need to cancel electives, they should be able to do so without recourse to a national or regional team for approval.

Bolstering the social care sector

As they have done throughout the pandemic, the social care workforce will play a critical role this winter in supporting people at home or in the community. Although the recent additional funding to help recruit and keep staff is welcome, we need to take stronger action to bolster the whole sector to continue delivering high-quality care for everyone who needs it. We also need to level the playing field and pay care staff the equivalent of what their NHS colleagues earn and reimburse them adequately for increasing costs, such as fuel.

  • Health and social care have many complex interdependencies that keep the system working. However, care sector capacity is limited by staffing constraints. Providers are reporting a 75 per cent reduction in applications for jobs and recent figures show 105,000 vacancies being advertised a day; a shortfall expected to deepen as a result of the mandatory vaccination requirement that will come into effect today (11 November) and make providing care increasingly difficult over winter.

    Shortages and issues with pay in the sector are the main drivers of the challenges. Their impact on capacity first and foremost means people are missing out on vital care and support. It also makes it harder to discharge people, who are medically fit, from hospital into care packages that help keep them safe at home. Apart from the negative impact on the people and their outcomes, this also slows down the flow of staff and patients through hospitals, affecting care available for others.

    This system-wide failure to provide care is not only shameful but is starting to impact on the health of our communities more generally, with higher and higher numbers of very sick people presenting in emergency departments. Finally, all these impacts, felt by patients and across the system, make it harder to tackle the serious backlog of healthcare due to the ongoing impact of the pandemic.

    Although the recently announced additional funding to support recruitment and retention of staff is welcome, it is not clear this will be sufficient to entice and maintain the numbers of staff required. Particularly in light of the Care Quality Commission’s forecast of a ‘tsunami of unmet need’ this winter, and despite adult social care having worked tirelessly to vastly increase home care capacity during the pandemic.

    We propose that there are two interventions that will make the difference now to better compensate and retain existing care staff and help to attract people to the profession. Firstly, we call for the pay of care staff to, at minimum, be increased to a rate equivalent in value to that being paid to staff on NHS Agenda for Change terms, to help raise the status of this essential work. This should be fully funded and distributed through local authorities, who will be able to ensure the funding reaches the front line, does not impact self-funders’ cost of care, and delivers an impact this winter.

    Secondly, the government should ensure care providers are funded so that they can fairly reimburse staff for rising costs and make care more equitable and attractive place to work. Many care staff will have recently lost the weekly Universal Credit uplift and may be hit by the National Insurance rise next year. For instance, care providers should be funded to be able to pay low-paid domiciliary workers, for whom driving is a significant part of the job, for recent increases in fuel prices. According to the Homecare Association, there could be over 5 billion miles driven every year in home care, however they receive less per mile compared to people who work for the NHS.

    Regarding funding, we welcomed the government’s recent extra investment in the NHS, but we cannot immediately buy our way out of this potential crisis where we face over 90,000 vacancies in the health service. That means it would be better to allocate more immediate money from the recent funding settlement to social care services. Boosting the numbers of care staff will have much greater impact on reducing pressures on hospitals and other parts of the NHS.

    These are not long-term solutions. We look forward to seeing further reforms that will stabilise the historically underfunded sector, including a comprehensive and funded system workforce plan to address long-standing challenges. We can no longer have plans for each component part of the system, they must be aligned, innovative, and reflect the approach in the long-term plan.

What the NHS needs from the public

There are simple steps that the public can take to make the best use of NHS services this winter, while demand for care is at an all-time high. We ask political leaders to support and communicate these public-facing messages:

Get vaccinated

  • Get your COVID-19 vaccinations. This is the single most important step you can take to protect you, your loved ones and the NHS. Being vaccinated means you are less likely to need emergency care, leaving NHS staff with more capacity to help other people this winter. 
  • Get vaccinated for flu. The jab could save your life and will help the NHS.
  • Get a COVID-19 booster jab if you are eligible. After five months your original vaccination will start to have less of an effect on protecting you from serious illness if you get COVID-19, so it is vital that you top up your immunity when you are called to. 

Do what you can to support your NHS

  • Help stop the spread of COVID-19 by following government advice.
  • Use your pharmacist to get help with minor health concerns.
  • Use NHS 111 if you have an urgent medical problem and you’re not sure what to do.
  • Make sure you don’t miss your medical appointment and if you need to reschedule give the service plenty of warning.
  • Consider volunteering for local charities, and supporting people in your street and communities.

What comes next?

Looking at the response from the front line and where we are on the trajectory of demand heading into winter, it is clear that something needs to be done differently. Even the additional funding announced recently has come too late to provide much needed extra capacity to avoid health services becoming unsafe. Being able to free up capacity to tackle the huge backlog of care for people whose care was cancelled during the pandemic feels like a distant ambition.

We have been calling for action in the run up to winter, including for ‘Plan B’ measures to be introduced. Now is the time to face up to the scale of the fast-approaching challenge and work in partnership – the NHS, the nation and political leaders – to avoid stumbling into a winter crisis. It is in this way that the whole system will be able to achieve the best possible outcomes in the coming months.