- Tim Cooksley, immediate past president, Society for Acute Medicine
The NHS remains under immense pressure.1 Each part of the system is experiencing demand beyond its capacity, which is continually increasing the problem. This is most vividly illustrated in urgent and emergency care settings. Media images in the next few weeks will portray long queues of ambulances outside emergency departments and patients experiencing prolonged periods of degrading corridor care. Publications will feature stories of patients who have experienced significant harm and trauma due to delayed ambulance responses.
Each winter in the past decade has become slightly worse,2 and that trend, which has not been reversed, has resulted in a dire situation that may not yet have reached its nadir. A continuum of often predictable perfect storms has caused a struggling system to reach collapse. Last winter this was exacerbated by a further wave of covid-19, high levels of influenza, and an outbreak of group A streptococcus infection with challenging cold weather. January will again see increases in covid, influenzae, and probably respiratory syncytial virus alongside the longest junior doctor strike in history. These problems arrive at a time of already overcrowded hospitals with dangerous levels of occupancy.
At its heart the crisis remains remarkably simple: there is insufficient workforce and capacity to meet the demands of an increasingly ageing and comorbid population. There is no resilience to cope with any excess strain caused by any of the highly predictable storms. High staff absence levels, burnout, and low morale continue to permeate throughout the NHS. Excess mortality rates and increasing numbers of patients waiting more than 12 hours in emergency departments illustrate the problem.3
The solutions are not easy, nor are they quick to implement, and it will take at least a decade to return to the delivery of high quality acute care. This uncomfortable reality needs political acceptance and a realisation that a focus on short term “wins” without a comprehensive long term strategy will condemn urgent and emergency care and the NHS as a whole to further deterioration. The perceived golden ticket of “artificial intelligence” will form part of the solution, but, unless insufficient workforce and capacity are tackled, this will inevitably fail. Strategies to manage increased demand, which seem conceptually sensible, have performed poorly in real world settings.
Too many deeply unacceptable occurrences are now perceived as “business as usual”—corridor care, high job vacancy rates and poor levels of staffing, long waiting lists, and more recently industrial action. All need focus, although arguably only industrial action has an immediate solution.
Collaborative position statements from medical royal colleges and societies have outlined the key clinical principles to support recovery. These are focused on improved communication between clinicians, continuity of care, and logistics with locally led innovation.4 It is essential that service and political leaders provide the resources needed and reduce unnecessary bureaucracy to enable national and local clinical leaders to drive forward and implement these changes.
The demand for acute care will continue to rise for the foreseeable future.5 The long term workforce plan desperately needs the support of a long term pay structure, which alongside clinical and capacity plans will be essential to rebuild the NHS. Innovative clinical solutions and dedication of staff continue throughout the NHS, but unless workforce and capacity are tackled then the inevitable future winter storms will continue to flood the NHS.
Footnotes
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Competing interests: None declared.
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Provenance and peer review: Commissioned, not externally peer reviewed.