'When pressures bite, the first thing to give is access to care'

By Nigel Edwards, Nuffield Trust and Dr Jennifer Dixon, The Health Foundation.

Blog post

Published: 08/12/2016

Our most striking finding is that, when pressures bite, the first thing to give is access to care. Waiting times for urgent and planned care have continued to slide throughout the duration of our QualityWatch programme to the point that most major targets are now being missed. While it should be remembered that English patients spend less time in A&E than their counterparts in many comparable countries, unacceptable delays for both emergency and planned care are nonetheless commonplace.

Just over a year ago, we said that the warning lights on care quality were glowing brighter, and predicted that patients would wait even longer for care in future; but pointed to quality being sustained and even improving in many important areas. On the surface, this year’s report seems to continue this story: care quality is being sustained in several areas – public health, patient satisfaction, and stroke care to name a few. These achievements are impressive in themselves, and even more so when taken against a backdrop of a period of financial austerity more severe than in any other time in the history of the health service.

Once again we plot the decline in access to care in this year’s report - waiting times for planned treatment and ambulance response times continue on a downward trend. It seems that timely access to care is being forfeited in order to provide high quality care once patients get into hospital. But for the first time, our analysis suggests that we may be reaching the point at which sacrificing access is no longer enough to manage the extreme pressures under which the NHS is operating.

It seems that timely access to care is being forfeited in order to provide high quality care once patients get into hospital

First, lengthening waits for treatment increase risks for the patients affected. Waiting longer may mean preventable conditions are not addressed, while delays in treatment can mean minor ailments become bigger problems. The considerable pressures under which ambulance services are working and the lengthening waits for ambulances responding to life threatening situations are deeply worrying.

Second, our report tracks a slowdown in the progress towards eradicating healthcare associated infections (HCAIs). While impressive improvements have historically been made in this area, progress in reducing some common HCAIs appears to have stalled, while others are on the rise. While the Secretary of State’s recent announcement on financial incentives for Trusts to reduce E. coli infections is welcome, a big risk factor is bed occupancy which remains at dangerously high levels. The risk to patient safety from HCAIs in the future is concerning.

Finally, it may be that financial and other pressures will lead to ‘delayed decline’ in areas of quality so far unaffected. The deterioration in waiting times we see now did not begin until some years into the current decade of austerity, suggesting that financial pressures take some time to translate into quality lapses.

Preventing a quicker decline may well have been down to the hard work and goodwill of staff. But with workforce shortages, pay freezes continuing across the NHS and last month’s Autumn Statement offering no relief from austerity in the NHS and social care for the remainder of the decade, we should be on high alert for any further decline in quality of care – whether patient experience, other waiting times, or patient safety.

For now, considering the extent and depth of the financial squeeze, many services within the NHS are still bearing up well. But the success stories we see through our ongoing analysis have, in large part, been the result of careful and targeted investment. Sustaining this in the face of growing financial, demographic and workforce pressures will be a considerable challenge.

There is no doubt that more can – and must – be done to make the NHS as efficient and effective as possible. The ideas and innovative thinking to improve and transform services are in ample supply within the health service, but the NHS needs a chance to deliver them, through intelligent investment, support and time. Failure to do so could put an already stretched NHS at risk of serious lapses of care. Patients deserve better than that.