NHS in a position of ‘national vulnerability’ as local services gear up for busiest period
Local NHS leaders are warning of huge pressure on their services in the coming days as the NHS faces up to its busiest few weeks of the year. They paint a picture of the NHS being placed in a position of “national vulnerability” as winter pressures grip the system.
The latest winter SitRep reveals the NHS in England is coming under increasing pressure, with flu cases in hospital “skyrocketing” to over 5,000 at the end of last week and “rising at a very concerning rate”. NHS England also warn that there is continual pressure from Covid-19, while RSV and norovirus cases in hospital are also higher than last year.
Alongside the data, local NHS leaders have been describing the increased pressures they are facing to the NHS Confederation, with several key issues emerging. More NHS trusts are expected to declare critical incidents in the days and weeks ahead, with primary care already seeing demand increase significantly after the holiday period. And the UK Health Security Agency has now issued a Cold-Health Alert for all regions of England – expected to last until 8 January – which will add to the pressure:
Spike in flu cases: NHS leaders are bracing themselves for flu cases to reach their highest levels of the winter period over the next two weeks. One acute trust director told the NHS Confederation: “We have a huge flu spike. I’ve never seen numbers like it. High numbers are coming through our emergency department with flu and RSV, so pressure on our cubicles has been high. We have now started to cohort due to the number of patients. It is worse than I have seen in previous years.”
This is adding to significant demand pressures on local services, with another acute trust director saying: “Our trust has been in an internal critical incident for nearly two weeks, with high levels of acuity, low discharges and ambulance waits for offload on some days of more than two hours.” A primary care leader added: “We are seeing lots of respiratory illness and norovirus, with lots of flu too and complex frailty issues for over 70-year-olds. We’re getting lots and lots of prescription requests.”
Staff absences: increasing flu cases are also impacting on NHS staff, with high levels of staff absenteeism. One acute trust director said: “We have seen a significant spike in staff sickness levels impacting on our minimum staffing levels. There is reluctance to pick up extra shifts, which I assume a lot is to do with the fact that colleagues are burnt out. Our summer was busier than last winter based on urgent care activity.”
High acuity and high demand: many trusts are reporting that they are seeing more patients, many of whom have worse health conditions. They report that this is impacting not just on the elderly and the frail, but also on a wide range of people with long term health conditions. One acute trust director said: “We're seeing higher acuity of patients through our emergency departments that are requiring admission due to acute medical/surgical reasons.”
Another acute trust director said: “On Monday morning we had the highest number of patients waiting for beds in our emergency department than we have ever had before – this was several wards worth of patients in corridors and waiting rooms and chairs. Worse is the acuity, and the overall higher acuity means a longer length of stay which results in even less capacity. We only expect it to get worse.” A primary care leader added: “Our winter illness clinic is fully booked. Lots of respiratory illness and then frail elderly patients with complex needs that aren’t being met.”
Infection prevention and control: due to the very high levels of flu and norovirus circulating in local communities, NHS trusts report difficulties in isolating patients with serious underlying health conditions from those with flu. Every case of norovirus adds huge pressure to wards as they have to be closed to admissions while being deep cleaned. This results in wards being temporarily closed and patients waiting longer to access beds.
Lack of beds: bed capacity is at 100% in many trusts, with many patients facing long waits for a bed, and trusts struggling to discharge patients back home due to a lack of available social care support. This is reducing the ‘flow’ of patients through hospitals, which is clogging up wards. One acute trust director said: “On Monday morning we had the highest number of patients waiting for beds in our emergency department than we have ever had before.”
Some trusts are now reporting that they are at maximum bed occupancy and starting to have to cancel elective activity, with one acute trust director saying: “We are now at maximum occupancy and resulting in delays/cancellation of some elective activity.”
The lack of social care capacity to safely discharge patients into is a common challenge, with one acute trust director saying: “We had very few discharges over the festive period resulting in maximum occupancy. As we continue to struggle with those awaiting social care the focus often is on discharging the more acute patients with use of virtual wards etc. Premature discharges are also leading to an increase in re-admissions which only delays the current bed flow problems.”
Re-directed capacity: some of the extra capacity that trusts have put in place to tackle winter, like same day emergency care, is being turned into regular ward capacity, which in turn increases four-hour waits in A&E. Many trusts are working hard to keep same day emergency care open, with one acute trust director saying: “Our trust is amazingly managing to not bed either the surgical or medical same day emergency care areas, recognising the importance of flow through these areas to reduce emergency department attendances.”
Impact on ambulances: these pressures are being felt across all parts of the system, with one ambulance trust director saying: “From an ambulance perspective, we are also very obviously being affected by the lack of flow in urgent and emergency care services. Vehicles in my trust are being held outside with patients in them for many hours, with sub-optimal environments for patient care affecting wellbeing of staff and patients. From a risk perspective, tissue viability, hydration and nutrition are an issue, plus once a vehicle is ‘stuck’ outside an emergency department, we cannot respond in the community to incoming 999 calls in a timely manner. Seeing extended response times for undifferentiated 999 calls is leading to overt harm.”
National and local NHS leaders were braced for a difficult winter given the service entered winter busier than ever before – with A&Es, ambulances, GP practices and mental health providers seeing record demand in October. The situation is being compounded by the highest levels of flu and norovirus that the NHS has experienced in years.
The NHS is continuing to do all it can to deliver safe care for patients. This includes putting in place thousands more beds, more ambulance call handlers, 24/7 care control rooms, respiratory hubs, expanding same-day emergency care services, as well as expanding virtual wards so more patients can receive hospital-style care at home. It has also ramped up efforts to ensure as many NHS staff and members of the public take up the flu vaccine, and for the first time this year the NHS is offering the RSV vaccine to those aged 75 to 79 and to pregnant women. However, despite these efforts, flu vaccination rates remain lower than they could be.
NHS trusts are also using some of the approaches that they developed during Covid-19 to help mitigate the risk to patients. Mask wearing is being reintroduced in some trusts, especially in vulnerable areas like oncology, and hospitals are finding new ways to open more bed capacity.
The public can also play their part, and the NHS Confederation is encouraging people to access the right services at the right time, to get vaccinated against flu and RSV in particular if eligible, and to take extra care of themselves and loved ones during the icy conditions that are expected shortly.
NHS Confederation chief executive Matthew Taylor said: “The NHS has done all it can in advance to mitigate risks to patients this winter, but we should be under no illusions that the service is in a position of national vulnerability as the intense pressures we are now seeing start to grip local services.
“These winter stats bear out what local NHS leaders have been telling us directly in recent days – that the NHS is facing huge demand, from sicker patients, with very high levels of flu to deal with. The next two to three weeks will likely be the busiest period of the year for many local services and we need to acknowledge the strain that this will place on staff and services.
“We encourage the public to do all they can to alleviate pressure on local services. That includes getting vaccinated for flu and RSV, as well as by making sure we all use the right NHS services at the right time. 111 should be the first port of call so that patients can easily access the appropriate advice and be directed to the most effective care, while pharmacies offer a range of services that can prevent the need to go to your GP or A&E.
“NHS staff know this is far from ideal, but we ask the public to understand the pressure that local services will continue to be under for the next few weeks.”
