Comment Blog 17 December, 2018

The NHS winter crises 

The 2019 NHS winter crises has followed the 2018 winter crises which came a year after the 2017 winter crises. The NHS has always found the extra pressure of increased morbidity and activity of the winter months a challenge, however the pace seems to be quickening and year on year the crises seems to be more apparent.

The reasons for this are multiple. From increased ageing and complexity associated with multimorbidity of non-communicable disease, difficulties in managing the health and social care divide, spikes of illness associated with seasonal upper respiratory infections, all of these factors play a part. Furthermore, the work put in by the people who man the wards and work within primary care is significant – indeed in many places’ heroic. Solutions are not associated with people working harder. However, the winter crises is now being joined by the manpower crises – as vacancies increase, rotas get more difficult to fill, and the pressure being felt by people within the system also increases leading to increased rates of burnout. We need to break this cycle as its effects are becoming more and more apparent.

Solutions to breaking this cycle cannot be expected to be simple, otherwise we would have already deployed them. However, there are two initiatives which will break this cycle:

  1. Adopt a “digital first” policy”. We need to address digital transformation not by layering digital adoption on existing services but by using the opportunities afforded by digital transformation to rethink existing care pathways. Also, a digital interaction with a health and care system is the default first approach between a patient and the system in the majority of cases for the majority of people. By thus segmenting demand, supplemented by also using new technologies from telemedicine to machine learning, we will be making our workforce go further as well as work in a more focused environment at the upper end of their competency. What we have done to date is implement in parts, with poor governance, tended to double run, and overlaid digital and technological solutions on pre-existing analogue ones.
  2. Start to deploy metrics which drive personalised population health systems. We have written volumes on the benefit of prevention and indeed set up structural reorganisations that would support this way of working. What we have never really done is systematically change the metrics that drive the system. Of course, one needs to proceed sequentially and not suddenly alter a system, but signalling we are aiming for 50% of income for providers to be tied to personalised population health initiatives and implementing this by diverting 5% of income year on year to deliver this, would be an option worth considering.

As long as we talk about these initiatives as an aspiration but do not put in place the mechanisms to support and drive them in the system, I see little hope that we will not be talking about the crises again around the same time next year and the year after.

Dr Charles Alessi is Chief Clinical Officer and the Healthcare Information and Management Systems Society and a Senior Advisor to Public Health England