As first published in the HSJ Insight and Influence Channel.

We are in mid-Winter.  We were told the NHS was never better prepared.  A significant ‘flu “epidemic”, relatively unusual cold conditions and a difficult Christmas (most of which were unpredictable) have all intervened.

Confidence has been shattered.  We have all viewed images, designed to be shocking, which portray a service apparently in extreme difficulties.  There are many causes and a single solution will not solve all issues.

People present to A & E, on self-referral, or through the Ambulance Service, or, through professional direction (GP services).

Very high expectations have been set as to the time limit within which patients will be assessed, treated, discharged or passed on for lengthier treatment.

One very significant issue is that those patients who need longer periods of hospital treatment cannot progress from A & E (sometimes even with a medical assessment unit (MAU)) which serves to hold in care patients who need longer term treatment but cannot be moved to their ultimate care destination because available capacity is full.

This capacity is often occupied by patients, too frail to move, unable to return home and for whom the necessary care facilities have not been approved for funding by NHS or local authority social services.

There is very little public sector provision for medium and long term care of chronic or irremediable conditions.  Over the years this provision has become an independent (private or voluntary) service.  This service is funded by a mixture of NHS (free at the point of delivery to all) Local Authority (means-tested) and private means resource.  That impenetrable and unmanageable cocktail cannot and does not work under the daily pressures of the demand which sees new patients arrive before others have completed their care journey to an appropriate placement.

Just like a road traffic jam, if those at the front cannot exit to relieve congestion, new arrivals will be held up with increasingly adverse consequences.

The crisis affects most gravely those who do not have their own resources to purchase the required placement.  Even some of those who have resources will be caught in the inertia of the roadblock and exacerbate the problem.

Many of the those affected are older, mentally ill and those with learning difficulties, often without caring family advocates to advance their cases.

By the very nature of their lack of capacity or limited capacity, self-advocacy is not realistic.  Often those with less acute needs see dependency rise rapidly whilst caught in the system.

However, on the other side, the medium and long term care sector has very significant capacity to relieve the log jam.  This availability can only be accessed if commissioner action commits to authorise placements with appropriate spend.  The problem is often not one of assessment time, as those blocking the care flow, have needs which are well known and understood.

 

There has been a lack of willingness: –

  1. On the part of the Care sector to share its availability;
  2. An absolute refusal by the care sector to be constructive and realistic about the financial resource required to fund the available capacity. The sector has been obsessed with delivering a business model based on a so-called fair price for care.  There is no such thing as a fair price for anything.  The issue is not the unit price but the total outturn revenue which determines financial success after deducting cost and produces thereby the necessary surplus to both reward and provide for investment.  It is known, but not articulated, that the top slice of service utilisation goes to surplus, thus driving a bottom line outcome which ensures sustainability.  This can never be achieved by measuring unit price separately from service utilisation. In short providers who encourage high utilisation can afford to cut unit price and improve not damage their services.
  3. Commissioners, both NHS and Local Authority Social Services Departments (LASSDs), are hopelessly slow to intervene to move those who no longer need hospital care into a more suitable and less expensive environment. Clearly there is a cash squeeze but constructive and proactive engagement with capacity holders could work to alleviate the pressure and increase availability for patients coming in at the beginning of the journey.  Serious and sensible negotiations could, relatively quickly unlock a lot of the pressure
  4. Commissioners are right to complain that their resources need a supplement but that is no reason not to actively endeavour to solve the problem. Providers should see the advantage of negotiating to maximise utilisation gain without sticking to a mantra of unit cost integrity
  5. This complex system with multiple stakeholders is a recipe of disaster. The answer is surely for the Health and Social Care Department, rather than handing out further grants to LASSDs and NHS commissioners, who simply cannot be trusted to apply the funding as required (absent enforced hypothecation), through other competing pressures, to commission direct into the available independent and voluntary sector capacity either directly or by way of debit to commissioning funds earmarked for relief of NHS bed blocking
  • Hospitals could easily identify the needs of those no longer needing expensive hospital in treatment
  • Providers could easily be constructive in pricing discounts in return for an increase in utilisation
  • The Health and Social Care Department has ample resources to fund directly or indirectly by funding resource to meet the obligations of Government Directions to commissioners
  • Additional funds would then be applied to quickly create a solution to the problem. Care costs would be reduced.  The pressures felt at A & E would be reduced amounting a return to “normality” where hospitals treat those in need of hospital care, rather, than having no option but to keep patients who can be treated in less expensive and more suitable placements.

 

This requires constructive engagement initiated by the Department for Health and Social Care who are the eventual key to resolution provided they have the will and ensure that additional funds are actually spent on the steps needed to address the problem.

 

The capacity is there.  Could there be a collaborative will to joint working to address the issue.

There is no lack of power in legislation to make this work.  The problem is the inertia created by a lack of time to think a little outside the box and take steps which achieve results and improve patient care.

 

This will not solve all the problems but could be a substantial start.