A whole-system approach to managing winter pressures

The Care Quality Commission has a unique view of the entire health and social care landscape, and over the next few weeks we will examine the impact of winter pressures across all sectors; share examples of where we are seeing good practice; and highlight the need to take a whole system approach to planning for and managing heightened demand.

In the first of our new blog series, Chief Inspector of Hospitals, Prof Ted Baker highlights the challenges facing health and social care and discusses our programme of focused inspections of emergency departments.

The latest State of care report noted that capacity issues once reserved for the winter months are now year-round. After a difficult summer we entered this winter with A&E performance at its worst level: July 2019 saw the highest proportion of emergency patients spending more than four hours in A&E than any previous July for at least the last five years. This was coupled with primary and community care services operating at full stretch, leaving little room for manoeuvre.

Heading into the winter season, providers across health and social care were braced for the impact of yet more surges in demand. Both NHS Confederation and NHS Providers highlighted health leaders’ predictions that this would be the ‘toughest winter on record’, raising concerns about the level of risk that would need to be managed for patients and staff alike. Weekly sitrep data has confirmed these predictions, revealing significant, sustained demand across the NHS.

Staff working across all health and social care settings are going to extraordinary lengths to try to maximise capacity and meet the ever-increasing need for services, and I commend their work. In our visits to emergency departments we regularly see staff working hard to maintain the quality of care despite the relentless pressure they face.

We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff and must not become normalised. Hospitals and emergency services cannot work alone to address the ever-increasing demand for care. We recognise that health and social care services are working more collaboratively and innovatively when it comes to planning for winter, but even greater system working, and integration are needed across the health and care system. The necessary reform must proceed at pace if we are going to make a difference before next winter.

Our local system reviews highlighted that where systems have established joined-up processes, effective prevention approaches and implementation of initiatives to avoid unnecessary hospital admissions, they are more likely to manage pressures well. Where this wasn’t happening, a number of the reviews identified ineffective coordination of health and care services, which led to fragmented care. The recommendations from that report still stand: there has to be a system-wide approach with all parts of the health and social care system working jointly to find solutions, including the Government and CQC.

Consideration of winter pressures is often focused on the performance of emergency departments, but the problems faced by individual services are symptomatic of a much wider capacity problem across the whole health and social care system. Solutions cannot be found within the emergency department alone, or within the hospital alone. A system-wide approach is essential.

But emergency departments need support now to manage the immediate problems they face. To this end we have continued our programme of focused inspections where our monitoring activity has identified potential safety risks. These one-day, clinician-led inspections quickly pinpoint where action is needed to improve care and keep patients safe. They focus on the five key pressure points that we know can have a crucial impact on resilience at times of peak demand:

  • Assessment and triage
  • Management of deteriorating patients
  • Patient flow through the department
  • Workforce
  • Leadership and culture in the department

Trusts receive immediate feedback, and the inspection reports are produced more quickly to support timely improvement. We have received positive feedback from providers that have received a focused winter inspection. The approach of a smaller, clinically-led inspection team, on site for one day with no requirement for a provider information return has reduced the burden on departments and has been recognised as a positive, supportive approach that encourages improvement.

The model can also be used as a framework for self-audit, and we would encourage providers to do this. Providers might also want to revisit our resources sharing practical solutions for safely managing increased demand in emergency departments and best practice from clinical leaders.

These focused inspections are intended to support trusts in making critical improvements that will have a positive impact for staff and patients. But this is only one piece of a complex jigsaw and the problems faced by health and social care services are not amenable to a quick fix or simple solution.

Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. It is clear that collaboration and system-wide planning for increased and changing demand need to happen now, and that we must continue to focus on the whole-system approach to ensure that we safeguard quality of care both now and into the future.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

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