The NHS is in ‘a desperate state’, can it be saved?

Investigations 3rd March, 2017

Sid Ryan

This long-read on the NHS looks at how our local NHS services are doing, and the latest news on the the ‘plan’ to save the NHS, the STP.

Health providers across the country are reporting some of their worst performance targets in years while simultaneously struggling to plan for the next five years of funding cuts required by the NHS’s ‘Sustainability and Transformation Plan’.

Despite consistent pressure to actually tell people what’s going on, the local NHS has only published the bare gist of what’s in store for Bristol. This leaves the general public very much in the dark about which services are to be cut, and how – even though the full plans were signed off by NHS regulators months ago.

Campaigners, councillors, patient organisations, local MPs have joined in chorus to criticise the plans on almost every conceivable grounds, yet they are set to be implemented regardless. What the future might hold for the NHS is scary, but in in many ways, what’s happening right now is even scarier.

North Bristol Trust can manage to deal with exactly one more patient referral next year.

On the brink? Or over it?

Yesterday, University Hospitals Bristol Trust (UHB) received an ‘outstanding’ rating from the Care Quality Commission. It was only two years ago that the Trust received a ‘requires improvement’ rating, which makes UHB the only Trust in the country able to make such a turnaround in such a short time. But don’t be lulled into a false sense of security, this rating perhaps says more about the dreadful state of the UK’s other hospitals than it does about UHB’s excellent performance.

The most immediate problem is capacity. It’s recommended that a hospital leaves 15% of its beds unoccupied, enough to have space to treat patients coming into the hospital, and once they’re admitted, to be able to move them around as their care requires. However, this target is a fantasy, the records literally don’t go back far enough to see when this was last achieved.

Bed occupancy at North Bristol Trust, the yellow line has been added to the original graph to show the recommended occupancy level of 85%.

So while an occupancy rate of 85% is recommended, UHB ran at 99% capacity in November, and 102% in December with patients spilling into the corridors. North Bristol Trust (NBT) has been operating at over 95% occupancy for over a year, with the most recent figures showing that 97.5% of its beds are occupied even after opening up extra bed-space.

This overcrowding doesn’t come without consequence, in November 28.3%, over 2000 patients, attending the BRI’s A&E department sat in pain for over four hours before being seen due to delays in admitting patients. And 20 people that month had their surgery cancelled at the last minute because there were no beds to put them in afterwards.

Less obvious is the effect on how patients are treated once they’re inside the hospitals. Because patients have to take whatever bed is available, the condition they are being treated for often doesn’t match the specialty ward they are staying on. Patients at the BRI spend around 2,000 ‘outlier bed-days’ being staying on wards that are not ideal for their care – adding another layer of risk to an already pressured system.

So far, things are just about holding together, and it is a testament to the staff that despite the pressures, the vast majority of patients still rate their experience in hospital so highly. At North Bristol Trust’s last board meeting, a nurse talked about how a patient’s family member became distraught about their mother being cared for in the corridor. It was only because it wasn’t busy right then that the nurse could sit with the patient for a whole hour, and restore some of the dignity lost by being cared for behind a thin curtain screen on a busy thoroughfare. A complaint was avoided, but the root of the problem remains.

The system is under the greatest pressure it has ever experienced and the trajectory seems to be downwards, and yet the respective boards of the NBT and UHB don’t seem alarmed. They are busy doing the best they can with what they have, but when it has been over three years since the hospital ran at the ‘safe’ 85% capacity it is easy to forget that operating without a safety net isn’t normal, and was never supposed to be.

Imagine how services across Bristol, Bath and North Somerset would cope if University Hospitals Bristol lost half of it’s £600m per year funding.

Cries of alarm

Outside of the NHS bubble, our other civic institutions are fighting a rearguard action to try and do something to avert a crisis almost everyone feels approaching. Last month at a full meeting of Bristol Council, a cross-party motion objecting to the STP was was presented by Labour Councillor Gill Kirk and the Green’s Cabinet Member for Health, Fi Hance.

The motion criticised the hushed and hurried way in which the plans were drawn up, stating that the goal of improved healthcare cannot be met while simultaneously carrying out ‘unfeasible’ budget cuts ‘that there is no safe way of implementing’. Cllr Kirk, whose speech received a standing ovation, said:

“I’ve been a nurse since 1985 and over the last week we’ve seen the NHS in the most desperate state that I can remember. We’ve seen A&E departments overwhelmed and people waiting for hours on trolleys and corridors. Cancelled cancer operations. Lengthy waits for GPs. And social care is so desperately underfunded that medically fit patients cannot be discharged to free up beds. These are the issues facing the NHS and they are caused by underfunding.’

Cllr Hance underscored the pressures that the NHS is currently under, noting that on her visit to the Bristol Royal Infirmary on the 16th January there were 72 patients, nearly three entire wards, awaiting discharge that couldn’t be transferred into the social care system. “There are areas of this plan that are supported, possible and sensible,” she said. “However, what is unsupported, unrealistic and frankly absurd, is the underlying premise of £305m cuts across our region, let alone the pace at which it is suggested.”

The most concrete action to come out of the day was to write a letter to the government, but you have to imagine that the Council’s general grievances, and specific criticisms, of the STP aren’t going to be a shock. Westminster’s Select Committees have been grilling senior officials from the Department of Health for months, to little avail.

“My line of questioning was based on the view that there is not enough money to deliver the plans,” says MP for Bristol South Karin Smyth, who sits on the Public Accounts Committee. She noted that the NHS plans were predicated on adequate funding for the programme, a healthy social care sector and falling numbers of admissions, none of which have materialised. “The principle of bringing together health bodies to create a plan is good, but it is clear that providing enough money is a real problem. If there is no change to the finances, I would expect NHS services to get worse, particularly in terms of waiting times and access to GPs.”

Quite what happens next is anyone’s guess. The rumblings from Westminster indicate that the Sustainable Transformation Plans are here to stay. There is nothing more to come. This is it, and Bristol, North Somerset and South Gloucestershire will have to deal with it.

Unfortunately, 22% of the STP funding has been withdrawn by the Department of Health, for reasons that only make sense in the topsy-turvy world of NHS finances.

What next?

So what exactly does this STP hold for Bristol? That information is not yet fit for public consumption. Each of the 15 NHS organisations in the Bristol, North Somerset and South Gloucester region submitted their proposals for cuts and ‘efficiencies’ to NHS England in late November, and after discussion with the regulators the finalised plans were submitted in late December. However, it could be another month before anything concrete is published.

Both the Bristol and South Gloucestershire branches of Healthwatch, the patient and public advocate organisation, have had to officially complain of the lack of information or engagement about the plan for the next two years. The Robert Woolley, Chief Executive of UHB and system leader for the STP, suggested in his reply that there is no time and no funding to move forward into ‘implementation planning’ let alone conduct the full programme of public and patient involvement which has been promised, and is also legally required under the NHS Contract.

As a minor concession, the small group of representatives from Healthwatch and the usual voluntary, community and social enterprise sector who get the opportunity to be formally interviewed about the STP has been expanded slightly. Although I was sad to learn that although I was on the list of recommended consultees, I was specifically disinvited, because ‘this isn’t a matter for the press’.

This is in line with national guidance, NHS England have orders out to deny information when it is requested so it can ‘control the national message’ about the 31% of CCG’s that expect A&E closures, the 23% reducing medical staff and the nearly 50% reducing the numbers of beds.

This approach to public engagement has already caused a considerable degree of panic, with the i incorrectly reporting that the A&E at Weston Hospital is ‘earmarked for closure’. In fact, the Weston Area Hospitals Trust (WAHT) is entering an as-yet-unsigned partnership with its neighbour UHB. Because the Trust can’t safety staff its wards, patients in critical condition will be sent to central Bristol, and this is somewhat offset with the intention to treat more patients with less complex needs.

The press office is insistent that this isn’t the ‘C-word’, closure, or the ‘D-word’, downgrade. And even though the two Trusts will start sharing management functions and sharing some funds, this isn’t the ‘M-word’, merger, either. In anycase, the Trust are seeking ‘engagement’, rather than an official consultation, on the future of the hospital and the likely impact on the already stretched services in central Bristol.

The next we are likely to hear about the STP is when a new chairman for the project is appointed. Mr Woolley, the current leader of the project is uncomfortable about his dual role as leader of the BNSSG region and chief executive of ones of its members, so is searching for a successor. Candidates are already being approached for the role but it is not clear whether patients and the public will have any say into who leads the project.

Missing money

The first problem for the incoming chairman will be dealing with is money – they will have to find £305m to axe from local services. For context, imagine how services across Bristol, Bath and North Somerset would cope if UHB lost half of it’s £600m per year funding.

But even if that level of savings can be identified, the STP team will need a block of capital funding to get all the new schemes off the ground. Unfortunately, a fifth of the funds to do this have been withdrawn by the Department of Health, for reasons that only make sense in the topsy-turvy world of NHS finances.

The STP comes with a £60m ‘Sustainability and Transformation Fund’, that is supposed to help pay for all the savings schemes required over the next few years. But the Department can’t simply give £60m to the ‘STP organisation’, because there is no such thing, and instead disburses a slice the money to each of the constituent organisations for them to pool amongst themselves.

But there’s a caveat to receiving this money, each organisation needs to meet the ‘financial control total’ set by the Department of Health, and University Hospitals Bristol Trust have given notice that they won’t meet theirs. Instead of the £22.8m surplus for 2017/18 that the Department wanted, UHB can only cut enough services to deliver a £5m surplus.

As a result of missing this financial target, UHB’s slice of the STP funding, £13.3m, disappears. Not only does this negatively impact UHB itself, pushing a ‘profitable’ Trust into arrears, but it means that UHB can no-longer contribute its portion of the STP funding for the whole region, leaving the project with only 78% of the money it expected.

“There’s no central fund for the STP, so UHB losing this money just adds to the system level financial gap,” says Robert Woolley, Chief Executive of UHB and system leader for the STP.  “We are determined that the system finances don’t impact patient care, but we’ll have to ask hard questions about the services we provide and how effective and efficient they are. The real problem is that now, when we’re doing the transformative work we’ve been saying we need for decades, we don’t have the time or the pump-primed resources to do it.”

Extract from North Bristol Trust’s Operational Plan

With the financial case for the STP so shaky, what we’re left with is some very fantastical thinking. North Bristol Trust released its Operational Plan for the next two years in response to a Freedom of Information request. Although it was a bare fraction of what was asked for, the scraps of information don’t paint an encouraging picture.

For instance, NBT estimates are that the organisation can manage to deal with exactly one more patient referral next year. The 125,064 patients sent to the hospital this year, is planned as 125,065 for the next. It’s possible that total referrals to NBT don’t increase next year, but perhaps only with divine intervention.

It should be no real no surprise that the numbers don’t stack up. Although the STP has been in the pipeline for over a year now, the Department have just decided to provide the funds for a core team to undertake this kind of complicated statistical juggling across the 15 different providers and commissioners.

Overall, the plan for our National Health Service would be laughable if only people weren’t literally going to die as a result. Comically under-resourced, wildly optimistic and with zero independent scrutiny – what’s been presented so far doesn’t inspire confidence that the NHS will survive, let alone recover.

We can only hope that central government changes its mind and actually funds the service, because if it doesn’t, there might not be much left of the NHS by the time we get round to designing the next plan.

If you’re concerned about the Sustainability and Transformation Plan and would like to give your views, you can contact Healthwatch or get in touch with Bristol CCG. If you’re too angry to fill in a survey, Protect Our NHS and Bristol People’s Assembly have organised 300 Bristolians to march on Parliament on the 4th March, and are your best port of call if you want to lend your support to the NHS.