Our urgent care system needs long-term rehabilitation to meet patients’ needs

With the NHS under relentless pressure this winter and as records keep getting broken for all the wrong reasons, Helen Buckingham takes a closer look at why hospitals are so full, and emphasises the importance of supporting and helping the health service’s staff.

Blog post

Published: 12/01/2023

The NHS performance statistics and newspaper headlines paint a stark picture of the urgent care system. Records are being broken, and not in a good way. More people than ever before are attending emergency departments; more than ever before are waiting more than four hours before admission, treatment or discharge; and perhaps most worrying of all, more people than ever before are waiting for more than 30 minutes in an ambulance before they even get into the emergency department.

The ambulances are full because the emergency departments are full. The EDs are full because the hospitals are full. And the hospitals are full because… well, this is where the analysis becomes more contested, and the causes likely to be multifactorial.

Hard times

There is a consensus that the broken social care system is creating problems for the NHS in discharging people who no longer need inpatient medical care. That is certainly true, but far from the whole truth. Our recent analysis shows that significant numbers of patients wait for home care – including care provided by NHS community staff – and for short-term rehabilitation. Comparisons with other OECD countries suggest that nations with stronger community health services were more resilient to the impact of the pandemic, and better able to recover subsequently.

The NHS is placing great hopes in the ‘virtual ward’ as a means of expanding capacity while providing appropriate care for patients, but NHS England’s own figures show that only about half of the planned virtual capacity has so far been delivered. This week’s announcement of further funding for care home capacity will release pressure to a certain extent, although as social care and nursing experts have highlighted, care home beds still require staff, and the risk is that we simply swap one form of institutionalisation for another.

Capacity inside hospitals would be stretched regardless of delayed transfers. Although staffing levels on paper have increased over time, so have turnover levels and sickness absence. The 2021 NHS Staff Survey showed worrying increases in reports of work-related stress and staff concerns about workforce gaps. Turnover in the nursing workforce has reached a peak of 11.5%.

There are other consequences to hospitals working at near-full capacity that tend to increase length of stay. These include moving patients between beds and wards, reduced continuity of care, and increases in hospital-acquired infections.

Physical capacity is also constrained. Backlog maintenance levels in the NHS have grown to £10.2 billion – £1 billion greater than the annual capital budget for the NHS – and in some hospitals is directly impacting on their capacity to provide patient care.

In addition to supply-side pressures, analysis from the IFS suggests that one reason for increased lengths of stay may be that patients who are admitted are sicker, even if this is hard to confirm definitively.

No quick fix

None of these issues are amenable to a quick fix. Investment in social care and in community services will make a difference. Capital investment – in community infrastructure as well as acute hospitals, in IT as well as buildings – will make a difference. Addressing the staffing gaps across the health and care system will make a difference. A focus on population health and addressing the causes of ill health will make a difference (at least against a counterfactual). But none of this will happen this winter.

So what can be done? In terms of service delivery, hospitals and ICSs are developing innovative approaches to improving flow through their systems. A number of trusts have been encouraged to pilot the ‘continuous flow’ model, although Dr Louella Vaughan has written on the need to be cautious before assuming that the model will work everywhere, and pointed out there are other better evidenced good practices not yet in place everywhere. They include decision-making earlier in the day, more efficient medicines management processes, and more extensive use of discharge lounges.

Supporting the staff we have

Perhaps the most important thing right now is to support the staff we have. As the pay dispute processes take further twists and turns, there are actions which individual employers and national bodies can take to improve day-to-day working conditions – and many are. Some hospitals continue to provide free meals and free parking for staff. Some are providing food and uniform banks to help with the cost-of-living crisis, which is affecting staff as much as it is patients.

More fundamentally, we need to address the significant mental health and emotional wellbeing issues among staff, which were engendered by the pandemic and are exacerbated by current stresses. These needs go well beyond ‘wellness initiatives’, important and well intended as they may be, and need to encompass training and support, especially for middle managers, and psychological support for both clinicians and managers, including senior leaders.

Our urgent care system is in need of critical care. There are immediate actions that can be taken to maintain life, but long-term rehabilitation will be required to ensure services are once again able to thrive, and meet patients’ needs in the way we all wish to see.

Suggested citation

Buckingham H (2023) ‘Our urgent care system needs long-term rehabilitation to meet patients’ needs’. Nuffield Trust blog.