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© 2019 by Professor Shafi Ahmed

Winter Pressure on the National Health Service

 

There is currently unprecedented demand on the NHS for visits to A and E and increasing pressure on beds, resulting in more cancellations of planned surgical operations. As a practising surgeon, looking after cancer patients, it is heartbreaking seeing operations cancelled on the day of surgery. Breaking this news to patients and relatives is a challenging process and it is often left to the surgeon alone to apologise for the failings of a system at breaking point. This is of course nothing compared to the disappointment and sometimes anger felt by a patient who has committed and prepared themselves for a major procedure with all of its inherent risks and the possibility of cure that that might follow.

Over the last 20 years since I qualified, the pressure of the winter season has always been present with cancellations of planned surgery being accepted as a fait accompli without questioning how we avoid this in future years. It is welcome news then that the government committed £400 million earlier this year to the NHS and have last month pledged a further £300 million for easing the pressure over the coming months. Despite this, the NHS has been asked to make £20 billion in savings through the so called ‘Nicholson challenge’. Even the most astute of NHS chief executives and finance directors are finding it hard to grapple with these mathematical conundrums. The challenge for frontline doctors and health professions is to make sure patient care is not being compromised in the meantime.

 So what are some of the potential solutions?

  • Better discharge planning to avoid re-admissions

I believe that hospital beds could be used more efficiently with a concentrated effort in avoiding unnecessary admissions from the community and through A and E and earliest appropriate discharge of patients from the hospitals. This incremental efficiency is vital for flow of patients throughout the hospital. This in turn requires close collaboration with social services to avoid ‘bed blockers’ and reduce early re-admissions.

  • Balancing the pressure between planned surgery and emergency surgery

Clearer protocols and standards on how patients undergoing emergency surgery should be treated and for the NHS are needed. The Royal College of Surgeons Emergency Surgery policy briefing is the beginning of the college’s efforts in improving the provision of emergency surgery. Ring-fencing beds for high dependency care, and ward beds for patients undergoing major elective surgery need to be considered to avoid the cancellation of high-risk patients. It would also reduce the potential harm to patients awaiting surgery.

Figures on cancelled operations released on Friday show that between October and November we saw a 17% increase in the cancellation of emergency surgery and an 11% increase in elective operations.  The BBCreported that visits to A&E topped 436,000 last week - nearly 30,000 more than the same week the year before. It is clear to everyone that the NHS is under pressure.

The NHS needs to make some difficult and tough choices about what capacity is available for elective and emergency surgery and the actual demand for its services. This capacity modelling is fundamental in managing this problem. NHS trusts need to have open and honest discussions with the CCGs when negotiating contracts and deciding how they are going to manage the workload for elective surgery addressing the predictable seasonal variations and increased demand. More importantly, they need to have long term, sustainable and robust plans in place for the elective surgery they cannot manage to deliver to the patients. Surgeons should not be put in a position where they have to inform a patient of their major operation being cancelled on the day of surgery. Our patients deserve more.