For your average Joe Blow it must be hard to work out why, every winter, there is such a commotion about pressures in the health service and particularly in A&E. Surely, after so many years, it could be sorted out? I think that puzzlement is also widespread amongst those of us working in or alongside the health service. After all winter pressures continue to be the focus of substantial policy, political and frontline thought, effort and initiatives. 
But, as with everything, it’s not as simple as it looks, and a number of issues, taken on their own fly under the “why is it still like this” radar. I’m going to try to unpick this. We have long talked about moving care into the community to manage the mounting demand for A&E services and to avoid unnecessarily lengthy stays in hospital.

Our recent survey of hospitals, mental health and community trusts in England showed that there has been a significant reduction in beds in community settings and over half (52%) said that it has been much more difficult to deal with demand for community services over the past two years.

So, far from increasing community capacity to manage A&E demand—which NHS Providers supports as the top line vision of the Five Year Forward View and a priority for the NHS—this is actually decreasing. Once you understand this it is easier to see why winter pressures are still with us. By why isn’t capacity increasing? I think there are four inter-linked reasons:

First, money that used be given annually to local systems to tackle winter pressures, and was a protected ‘pot’ of funds, has now been absorbed into commissioners’ general budgets. And, although tackling winter pressures is a priority, they will have to compete with other local priorities for investment.

Second, the substantial pressure on council and local commissioning budgets has, quite simply, resulted in less capacity to invest in community services. The cuts to local authority budgets as well as the severe problems in social care have a double impact. There is insufficient support for those needing to leave hospital, or to receive care in their own home. And, importantly, wider public health services, such as drug, alcohol and sexual health services, are commissioned less extensively, increasing demand on other, often emergency, services both acute and mental health.

Third, the Government’s Better Care Fund programme, which was designed to fast track integration between health and social care and deliver more care outside of hospitals, is not delivering in the way it was expected. A recent report showed that councils are not meeting their targets here, which is very concerning given the investment to date in this programme.

Finally, the way that these services are commissioned and paid for compounds the situation. Funding is often diverted away from community based and mental health care, because in the sequence of decisions commissioners tend to focus on sorting volume based services (usually in an acute setting) paid for by a tariff before the others.

Obviously trusts are not passively standing back. Many are delivering their own social care and community services to manage the demand. However this is not enough. In our survey when asked whether reinstating the lost beds and services would help them meet demand most respondents said it would only go some of the way. Transforming services is more critical. This is the vision of the five year forward view, this should be the solution to winter pressures, but the reasons why we can’t deliver this at the moment fly right under the radar.

Saffron Cordery, director of policy and strategy, NHS Providers.

Competing interests: None declared.