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Early approach to winter planning for urgent and emergency care is vital – but we must act now

The Royal College of Physicians (RCP), Society for Acute Medicine (SAM), British Thoracic Society (BTS) and British Geriatrics Society (BGS) have responded to NHS England’s national approach to 2023/24 winter planning. Workforce is the main limiting factor and hospitals can maximise their impact through four evidence based interventions.

NHS England’s early start to preparing for winter is vital - particularly support with operational and surge planning, which must come soon. The delivery of the 10 high impact interventions must be led jointly by clinical, operational and managerial teams.

But while the early start to avert a crisis in winter is crucial, we must also act now. Urgent and emergency care in the NHS is already in an unacceptable condition, and demand is high all year round. Patients are coming to harm, as our colleague Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said in the Independent this weekend.

We welcome the NHS England workforce plan and government funding, but it will take years to make a difference. The funding pledged to the NHS this year, while significant, is still not enough for the levels of demand we are experiencing now, let alone what we expect in winter. Ongoing disputes with government over pay are exacerbating the situation with cancellations and increased waiting times. They must be resolved as quickly as possible.

We also need clarity and transparency if we are going to resolve this situation. For example, the headline figure of 5,000 additional hospital beds may not increase capacity significantly as most of these beds have been open since last winter, but at least they are now funded. Also, if each hospital already has one or two wards’ worth of patients in its emergency department, corridors or waiting in ambulances to be admitted, this represents thousands of ‘beds’ already in existence. More staffed wards are required. RCEM has estimated that the current staffed bed base in England alone needs to increase by at least 8,500.

The workforce plan does not address a critical link in the patient pathway - social care. The £600m pledged last week to help with recruitment and retention is welcome, but we agree with the King’s Fund that it is not the sustainable approach that is needed.

Turning to the NHS England winter plan, the incentivised aim of 80% of patients being admitted, transferred, or discharged within four hours is an improvement on 76%. But it is still not ambitious enough - it will leave emergency departments still significantly crowded.

We must remember that NHS staff continue to strive to deliver high levels of excellent care, day and night, despite significant pressure over several years. It is right that the plan says trusts must improve the experience of those working in the NHS to improve retention and attendance. But simply asking them to focus on all elements of the ‘People Promise’ is not enough.

Progress towards meeting the promise, as measured by the Staff Survey, should be incentivised alongside operational performance. Because the most challenging part of the plan for providers will be to “ensure that robust workforce plans are in place to respond to an increase in demand over the winter period, including planning annual leave to maintain a continuous physician presence throughout the Christmas/New Year period.” Bearing in mind that NHS staff sickness rates were ‘unprecedented’ last year, this planning must include making sure that everyone working over that period has had a break before it.

Given the size of the workforce is inadequate for the scale of demand, clinical and organisational leaders must work with clinical teams to ensure the right skills are used at the right points in the pathway. This will help to limit unnecessary admissions, provide the right care to people requiring hospital stays as early as possible, and support people at home when they are well enough to be transferred.

We believe hospitals can maximise the impact of the current workforce by making four evidence based interventions:

1. As always, prevention of as much ill health as possible is key. People with chronic respiratory disease must have planned reviews for treatment optimisation and exacerbation plans before winter. Flu and COVID-19 vaccinations are essential for these and other patients with long term conditions, so all clinical teams must enable their delivery. Appropriate specialist follow up after admission in these and many conditions can prevent readmission.

2. We are pleased to see the emphasis on older people with frailty in the plan. We recommend early screening for frailty of admissions for people over 65 with Clinical Frailty Scale and 4AT (for delirium). This identifies people who need rapid frailty assessment by specialist multi-professional teams. Front door frailty care must be a priority for these clinicians.

3. We welcome the focus for ICBs to ensure effective system working and agree that all parts play their role. Hospitals can reduce length of stay and use the current workforce efficiently by making sure the right teams are in place.

  • Right size and staffing of acute admission units and SDEC units so that people who can be treated without admission are, and patients requiring short lengths of stay (48-72 hours) receive optimal care,
  • Patients requiring longer hospital stays must be cared for by the appropriate multidisciplinary clinical teams.
  • Current ‘temporary beds’ or ‘outliers’ should be converted into multidisciplinary medical wards.

4. With around 12,000 hospital patients ready to receive care at home or in other community facilities, we agree that greater focus on coordinating discharge is vital. This is already being done well in around a third of hospitals and must be replicated across the system. It requires close collaboration between ward teams and care coordination teams. Discharge to Assess, and early supported discharge - particularly for patients with COPD and heart failure - must be maximised. Hospital at home teams should be focused on these pathways.

The RCP and specialty societies will share best practice and work with NHS leaders to accelerate Urgent and Emergency Care recovery plans. We will also highlight the barriers to achieving these focused interventions and how they can be overcome. It is important that all clinical and operational leaders work together locally and nationally to do the same.

While the 10 high impact interventions can contribute to improving urgent and emergency care,  focussing on the four that we outline - that are evidence based and achievable with current workforce constraints - will bring the most benefit.

Dr Sarah Clarke, president, RCP
Professor Adam Gordon, president, British Geriatrics Society
Professor Onn Min Kon, president, British Thoracic Society
Dr Tim Cooksley, president, Society for Acute Medicine