2020 has certainly been a year which will remain in the history books; Covid-19 has shaken the country and impacted every aspect of the way we live our lives. The toll the pandemic has taken on public services is immense, and as we head into winter, the usual seasonal strain placed on our NHS is set to be intensified. In this blog, we take a look at the winter pressures faced by the NHS and consider how this year may be more challenging than ever.
Covid-19 aside, winter is always a difficult time in the NHS. Cold weather brings a mix of flu, winter vomiting bugs and respiratory conditions that affect patients and staff alike. Many existing health conditions, such as respiratory and cardiovascular diseases, can worsen in the winter months.
The impact of cold weather on people’s health is significant and the temperature does not need to get very cold either. Even moderately cold weather (classed as when the average daily temperature is between 5–8 0C) has an impact and each 1oC drop in average daily temperature results in a 4% increase in death rates in England.
Moderately cold weather also causes an increase in emergency hospital admissions of approximately 1% for each 1oC drop in temperature below the threshold. Interestingly, the number of A&E attendances actually decreases over winter, but the proportion of people admitted increases.
Vulnerable people, including the elderly, the disabled and those living in poverty, are much more likely to need to access healthcare in the winter months. Year after year, hospitals get fuller, often reaching maximum capacity, and patients must wait longer for care. Images in the media of patients queuing in A&E on trollies waiting to be assessed, are all too common.
“This winter will no doubt put additional strain on our NHS due to the current pandemic. It is critical that we work collaboratively with our NHS Trusts to support them at this difficult time and to ensure that we collectively continue to provide a service within the communities we both live and work” Steve Edgson, Regional Business Manager, Vinci
The Patients Journey
An important indicator of if a hospital is overloaded, is if they can meet the four-hour patient admission target. Higher bed occupancy in the winter months has an impact on the ability of a hospital to manage busy A&E units, leaving many people waiting way beyond the four hour window.
A higher proportion of patients stay in hospital longer in winter, meaning hospitals have even less flexibility to manage any peaks in demand. A huge challenge for hospital staff is to free up beds for newly arrived patients, whilst also ensuring patients are well enough to be discharged. Often, patients who are ready to leave hospital are unable to be safety discharged for practical reasons, such as the availability of transport or follow on care in their home.
Older adults are at greater risk of losing their independence after a long stay in hospital; they lose muscle power, strength and abilities due to restricted mobility. It’s imperative to enable patients to leave hospital as soon as they are well enough by providing the community care they need to continue their recovery at home and return to their previous routines and activities.
Prolonged stays in hospital lead to a cycle of admission, discharge and then readmission, highlighting the complex, interconnected social issues which lead to ill health. An important part of reducing admission rates relates to preventing people from falling into crisis in the gap between home and hospital, between social care and the health service.
Cancelled Operations and Quality of Care Concerns
During the winter months when hospitals are likely to be running at maximum capacity, the number of cancelled elective operations peaks. More urgent admissions can result in planned operations and procedures being cancelled at the last minute due to a lack of ward beds, equipment or theatre staff. When resources are constrained, people who are admitted to hospital in an emergency are prioritised, as we saw with the Covid-19 pandemic this year when all elective surgeries were postponed.
Although this strategy helps in the short-term to alleviate the immediate pressure, in the long term, it only adds to waiting lists and creates a challenging treatment backlog, not to mention the distress caused to the patients.
Concern over patient wellbeing doesn’t only come from cancelled operations. Despite the best efforts of hard-working and committed hospital staff, working in a hospital which is running at maximum capacity is not the ideal way to achieve high levels of patient care.
Busy hospital wards and high levels of bed occupancy are associated with higher rates of infections such as MRSA and Clostridium difficile, which only add to the strain on staff. Whilst there is very little data on how winter pressure effects quality of care, it is the staff themselves who have warned that that the demands placed on them during these months are becoming unsustainable. It is often only the professionalism and dedication of the NHS staff which keeps patients safe against the odds.
“The issue with dealing with winter pressures in addition to the Covid-19 and delayed elective surgery means that the NHS is under extreme pressure over the next few months and into 2021. It is important that our industry supports the NHS in dealing with these extremes and ensures that any capital programme works are delivered safely and without further disruption.” Phil Shaw, Divisional Director, Interserve
For most of this decade the NHS has been dependent on extra funding to get through winter crisis. In most years, this winter funding has generally been ‘topped up’ in November as need is assessed and the overall picture became clearer.
Many hospitals have criticised the level of winter funding as being woefully inadequate and only touching the surface of issue. The challenges that hospitals face in winter are actually present all year round, winter simply exacerbates them, and they certainly can’t be resolved in the medium or long term with the amount of winter funding that has been on offer to date. The resilience required to get through winter peaks is hard to achieve with bits and pieces of funding released in fits and starts throughout the year and encourages a more ‘reactive’ approach rather than allows for effective planning.
How will Covid-19 affect the NHS this Winter?
Of course, a huge concern this year is that all the usual winter issues will be intensified further by the current Covid-19 pandemic. Staff are already exhausted, having worked flat out since the spring. There are also many vacancies which the NHS is struggling to fill and additional resource issues arising from staff having to isolate.
On top of the usual rise in inpatients, this winter the NHS could also face an influx of patients who have put off coming to hospitals and accessing healthcare services during the first wave of the pandemic. The suspension of many routine clinical services during the pandemic is likely to result in an increase in cases of poorly managed chronic conditions or undiagnosed diseases. The Academy of Medical Sciences estimates that the overall waiting list in England could increase from 4.2 million (pre-COVID-19) to approximately 10 million by the end of the year. Alongside this, Hospitals must also deal with the logistical challenges of keeping patients separate due to Covid-19 infection protocol, reducing the capacity of already over-stretched facilities, even further.
A System Under Pressure
With an ageing population, an under-funded system and not enough staff, even without the additional pressures of Covid-19, the NHS faces significant challenges each winter. Life on the wards can be tense for both staff and patients and a lack of free beds can make things stressful for everyone.
The winter brutally exposes the gaps in the NHS, highlighting the pressures staff are under to meet the needs of patients. Effects are felt across the whole system, from the community and primary care sectors, through to the frontline services of A&E, winter only further depletes an already over-stretched service. The NHS seems to be caught in a perpetual cycle of trying to deal with challenges which arrive each winter, whilst never being given the opportunity to fully-recover.
“With the strain on the NHS system obvious to see during the winter months, the key to tackle the issue is increased communication. Whether that is by encouraging more people to seek advice from a pharmacist at the first sign of illness, rather than letting problems escalate or through the increased use of online services to self-diagnose issues which they can subsequently treat earlier in the home. Coupled with this there needs to be an increased take-up of readily available immunisations. For instance more people need to get their free flu jab in readiness for the winter period, this could be further promoted by increased engagement campaigns targeting staff, patients and other eligible members of the public.
Winter can be an extremely tough time both mentally and physically, helping people maintain their physical health is vitally important, community park-runs for instance provides a way both to stay physically and mentally fit. BAM actively promote a healthy work life balance and have a number of mental health ambassadors in place on both a regional and national level and also provide gym subscriptions for employees to maintain an active life-style.” James Bravington, Midlands Business Development Manager, BAM