Jan Filochowski: No room at the inn—the NHS today?

jan_filochowskiThe NHS’s critical problem today is not that things are bad, it is that they are getting much worse at a very fast rate across the board.

In 40 years involvement in managing NHS services I have never known a time when they haven’t been under pressure from rising demand or when governments haven’t said they are giving more to cope with the rise. That’s the official narrative today too, in response to weekly stories of increased pressure and longer waits.

But today the reality is dramatically different in a way I have never seen before. Demand is indeed rising a little (5% pa), as it always has, but the NHS’s ability to meet it is falling astonishingly fast. In a year, virtually all key waiting times and waiting lists have risen not by 5% but variously by 25, 50, or even 100%. Compared to a year ago, twice as many people are waiting over four hours to get treated in A&E; referral to treatment waits of over 26 weeks for surgery have increased by 65%; ambulances waiting over an hour to get patients into hospital have doubled; patients waiting over four hours on a trolley for a bed are up 40%; delayed discharges and bed days lost because of them have increased by 30%; and so on and so forth.

This isn’t a complete bolt from the blue though. In five years patients waiting over four hours in A&E to get treated and on trolleys to get a hospital bed have both increased by 500%. So the current position was foreseeable and hence avoidable.

So what? Can’t people just keep doing their best?

The simple arithmetical answer is “no.” These increases are the numerical difference between capacity and demand. That difference is not being bridged as in the past by using up slack elsewhere, because today the pressure is everywhere. Indeed, the trends suggest the gap is widening. So, the monthly figures for people waiting over four hours for A&E treatment were 125,000 last year and 250,000 this year. At the same rate of decline, it will be 375,000 in next year and half a million in 2 years’ time! A similar frightening calculation can be applied to elective surgical waits, initiating cancer treatments, ambulance response times, delayed discharges, acute psychiatric admissions, ITU and PICU admissions, and transfers, and more.

Sooner or later ballooning treatment waits will turn into non-treatment. They did 25 years ago when waits ran out of control, and no treatment meant a great increase in patient suffering and harm.

More capacity is indisputably needed: more beds and more staff, but these are not being planned for. Instead the NHS continues to bet the bank on actions to reduce demand despite its consistent failure to do so in the past, and overwhelming evidence that demand will keep growing. In the 90s demand exceeded capacity so waits increased. In the 2000s they fell as capacity was increased until it exceeded underlying demand. Now we’re back to the 90s.

The mushrooming shortfall in capacity also increases inefficiency because the queues created slow everything down and make services much harder to manage safely, the NHS’s very own traffic jam. The commonsense myth that unless you use facilities fully you waste resource has much to answer for here. In truth, unless you have enough spare capacity to deal with high as well as average demand, flow stops, blockages appear and chaos ensues, all of which are costly.

Is that the NHS today? Well, the Nuffield Trust has recently reported 95% bed occupancy last winter against an appropriate 85% maximum for safe care, warning of the adverse consequences of highly likely increases this winter. So, yes, it is.

Some of the most worrying effects of running out of capacity show up in the most serious cases, meaning increasing numbers of the sickest patients, and those needing intensive care, are forced to travel from one end of the UK to the other in search of a bed. This problem was acute when I was involved in managing specialist children’s services three years ago. We highlighted the need to increase capacity then. Action could and should have been taken by national funders but it wasn’t. Now the shortage is extreme, and the fallback options have nearly all run out.

To conclude, carrying on as we are will inevitably mean things continuing to worsen materially. How far do we have to slide down the slippery slope before action is taken to close the fast widening gaps?

Jan Filochowski is a visiting professor at Brunel University 2004-16, and was an NHS CEO for 20 years. Since he retired as CEO of Great Ormond Street three years ago, he has written and lectured about the NHS, and about managing to turn around failing organisations, using the insights in his 2013 book “Too Good To Fail?”. He has chaired several CQC inspections, and advised the Namibian Government on ways of improving management of health services in Namibia.

Footnote: The data in this blog come from NHS England. However, the %-s are the authors own arithmetic calculations based on this data.