Growing demand for beds is big challenge

AT a time when the NHS is having to make savings to balance its budgets – albeit budgets protected from major public sector cuts – managers have to contend with a huge new inspection regime.

Yesterday, we reported how health chief Sir Jonathan Michael expects next week’s Care Quality Commission (CQC) inspection to be “much more comprehensive” and “more complex” than ever before following the fall out out of the Mid Staffs scandal and subsequent pulic inquiry.

The CQC has accepted some of its previous inspections may have been “flawed” after it failed to pick up on poor care and high mortality rates at Mid Staffordshire NHS Foundation Trust.

In Oxfordshire, inspectors will now judge whether our hospitals should be rated outstanding, good, requires improvement or inadequate.

A rating of good or above will remove a hurdle to foundation status, giving the OUHT greater control over decision-making and finances.

The key challenge facing hospitals like Oxford’s John Radcliffe and Banbury’s Horton General is rising demand, such as a hike in emergency admissions from 79,940 in 2009-10 to 88,316 last year.

Sir Jonathan pointed out that the hospitals beds are at any given time mostly 98 to 100 per cent full against a recommended level of 85 to 90 per cent.

This makes the “flow” of patients through the hospital “very difficult” he said, particularly in the A&E department, where many are not admitted because of a lack of beds.

BED BLOCKING

As well as sheer demand, beds are often occupied by someone – usually a frail elderly person – who is well enough to go home but cannot because community-based services, mostly organised by Oxfordshire County Council, are not yet available.
This means the bed is “blocked” and, as well as causing delays in A&E, can lead to operations being cancelled as a bed is no longer available for that patient.

Last month we reported that patients face being denied a discharge to a bed in a community hospital nearest their home because of the bed blocking crisis.

Despite £10.2m to tackle such “winter pressures” from the Government, the “planned reduction has not materialised,” an NHS report admitted and the county is often cited, by Sir Jonathan included, as England’s worst.

Key to solving the issue is the trust working with Oxfordshire County Council, which commissions care firms to provide support in the home so people can leave hospital.

But Sir Jonathan said: “One of the difficulties is the speed with which organisations can escalate their activity and respond to requests for support.

“I am not in any sense trying to point a finger of blame at any organisation.
It is within part of a system that we don’t actually control.”

PLANNING FOR DEMAND

ONE of the problems this has created is the flow of NHS cash.
The trust gets most of its funds – £822m turnover last year – from Oxfordshire Clinical Commissioning Group (OCCG), created as part of a controversial shake-up of the NHS last year.

This decides where money should be spent, a “market forces” reform of the kind favoured by Margaret Thatcher in a bid to get providers like OUHT to “up their game” and compete for business.

But OCCG is being billed for more than it expects hospitals to do, Sir Jonathan said, meaning it faces a deficit of up to £11m in its first year, not a good start for a move designed to improve management of the NHS.

Sir Jonathan said: “We are a little bit ahead of what we thought would happen. We are significantly ahead of what the CCG planned to happen.”
Yet with both beholden to Government waiting time targets, he said the trust has no choice but to continue to treat people, whatever the cost.

ALCOHOL

WHILE improved treatments mean many are living longer, this does not mean people who are seen are in the best of general health.

Lifestyle habits like smoking, junk food and alcohol at the very least complicate existing conditions, like chronic obstructive pulmonary disease, adding to pressure on the NHS.

The 2007 smoking ban in enclosed public places was seen as a major step towards tackling smoking but a much-vaunted hit on alcohol with a minimum price per unit was shelved last year.

Sir Jonathan said: “I was in favour of the principal of minimum pricing for alcohol.

“It seemed to me to be a sensible way of dealing with it, using a financial lever to try and manage demand.”

ACCIDENT & EMERGENCY

TRUSTS have to admit, transfer or discharge at least 95 per cent of all A&E attendees in four hours but the trust has missed this every week apart from two since October 20.

Latest data, for the week ending February 9, shows 2,206 attended A&E and 191 had to wait more than four hours.

Sir Jonathan said a study of those who wait over four hours found they do so “because of capacity problems, which means capacity to find them a bed”.

Better waiting times raised expectations, he added: “When you had to wait for 12 hours in A&E, being sent to A&E was almost like a punishment.
“Now it may be just easier to jump in the car. So we do see people who perhaps could have been cared for or dealt with either the next day or by another system.”

BEING EFFICIENT TO FIND CAPACITY

FINDING “capacity” through making sure the throughput of the hospital is as efficient as possible can only go so far and there will always be an argument for simply adding more staff and beds to meet demand.

Sir Jonathan said: “The Francis review [into Mid Staffs] clearly identified the relationship between staffing levels, staff skill mix and quality of care and we have got to get that right.

“We have identified some areas where there is pressure, particularly at night. We have made additional investment to put in additional nursing staff.”

This is where workload has been “heaviest” like emergency wards, he said.

LIVING LONGER

ANOTHER key issue putting pressure on the system is increased life expectancy.

Sir Jonathan said: “We see more degenerative diseases now as people get older and bits of them wear out.

“Diseases that were a real problem in the past are now perhaps becoming less of a killer and more of a chronic disease.”

A trained doctor, he pointed to kidney diseases that were “almost universally fatal” while people can now be treated with transplants and dialysis. He said: “Living with a chronic disease is now much more common.”

BALANCING THE BOOKS

ALL of this, however, needs to be paid for and the trust has to cut costs to balance the books.

Sir Jonathan said: “We have to work within an economic environment and that includes pretty tough efficiency savings required by the NHS financial regime.

“Is it possible? Yes, absolutely. Is it easy? No.” The trust has to make efficiency savings of £44.7m this year.

He said: “There is a relationship between the finances and the quality of services provided and our job is to make sure we deliver the financial and quality performance.

“Can I guarantee we get that relationship right? No.”

He said: “The focus of the NHS has been more on the quality of the care than perhaps the finances. We are not going to allow the quality of care to be compromised. That is the challenge.”