How are hospitals like the Great Western coping with the new NHS – and how will it survive the Better Care Fund?

Written by Tony Millett.

First year report on the coalition government’s major NHS shake-up – part three

Hospitals were the one major part of the NHS in England not directly affected by the Lansley restructuring through the Health and Social Care Act.  But during the past year, hospitals have been in the eye of an NHS storm – not least because of their finances.  

Last month the trusts’ regulator, Monitor, announced that the number of NHS Foundation Trusts in England in financial difficulty had doubled over twelve months from 21 to 39 - of these 33 were acute hospitals.  

They have been caught in the down-draught from the Act – most notably from the requirement to put services out to tender and the increasing moves to favour commercial providers.

Acute hospitals – like the Great Western – are reeling under the pressures of increasing demands for treatment at a time of highly constrained budgets.  This may be partly because of the restructuring and partly because of other more general causes.

This unparalleled demand stems also from the growing population and its increasing longevity, from increases in chronic disease like diabetes (often connected to obesity), coronary and respiratory conditions – and the costs of new treatments.

The restructuring has undoubtedly given unprecedented commissioning power to GPs who are keen to enhance local primary care services and keep as many patients as possible away from expensive hospital beds and even more expensive hospital operating theatres.

But it was the aftermath of the Mid-Staffordshire hospital scandal in the shape of the Francis Report that has concentrated minds within hospitals and given politicians free rein to take pot shots at them.

That hospitals should have sufficient numbers of nurses was one of the key points of the Francis Report.  During the first years of the coalition government, nursing numbers fell disastrously – between 2010 and 2012 the NHS lost 4,028 full-time equivalent qualified nursing posts.  The GWH has been running a costly and successful recruitment campaign.

When reports on Mid-Staffs were published, nurses became the target of criticisms by right wing politicians and newspapers, not just because they were employed in the public sector, but because they were ‘too posh to wash’ or were not being ‘taught compassion’.

As winter approached the number of nurses (like GPs, many nurses choose to work part time, so these numbers are in terms of full time equivalents) rose dramatically: between September and November last year the NHS employed 4,500 additional full-time equivalent nurses for acute and older people’s wards – a three per cent increase in staffing levels at April 2013.

Even so, hospitals reported their budgets for agency nurses were going through the proverbial roof.  And it was only in January that the government allowed an increasing in student nursing places.

The general slide towards privatisation of NHS services reached its peak when the chairman of the Care Quality Commission, David Prior, (a former deputy chairman and chief executive of the Conservative party and a former Conservative MP) announced recently that ‘failing’ hospital trusts should sold off to European or American ‘hospital chains’.

He said up to thirty hospitals could end up being sold off to private operators.  This puts hospitals, whether they are Foundation Trusts or not, on notice that the government’s preferred way of solving costly problems in the NHS is by ordering fire sales.

As if the Health and Social Care Act was not enough, there will soon be the Care Act (which is expected to become law later this year.)  This Bill has had tacked onto it a clause (Clause 119) that may affect all hospitals.  

Health Secretary, Jeremy Hunt is changing the law so he can close down hospitals without reference to troublesome things like local opinion and competition issues.  This Bill - with its Clause 119 safely approved by MPs - is about to go back to the House of Lords for its final parliamentary scrutiny.

The NHS’ first year under the new regime ends just as winter pressures are beginning to ease. GWH has not had an easy winter.  
It bid for £4.2 million to help it through the winter – and got nothing.  The RUH in Bath got £4.4 million and Oxford University Hospitals NHS Trust got £10 million.

For many weeks over the winter GWH has failed to hit the target figure that 95 per cent of people coming to A&E should be seen within four hours. And it has suffered from all the connected problems of overcrowded emergency departments – ambulances queuing, trolley waits and blocked beds.

One Commentator has called A&E “the canary in the mine; it tells the story of what is going on elsewhere in the service.”

GWH has been working closely with GPs to make sure patients are referred directly to the right department and do not just show up at the emergency department.  A new urgent care centre managed by SEQOL opened on the GWH site in September. SEQOL is a Swindon based social enterprise organisation – “a business with a social purpose”.

And GWH is working with Wiltshire CCG on the Choose Well campaign – another way of encouraging patients not to use the emergency department as a first port of call.

Then in November NHS England found more money to prevent a winter breakdown at hospitals. £711,000 went to Wiltshire CCG and was passed on to Salisbury Foundation Trust hospital which used it for seven projects to help directly with winter pressures:

•    extending their discharge lounge to help the flow of patients.
•    establishing a unit for rapid assessment of the frail elderly.
•    an enhanced paediatric service.
•    extra support for its seven day service.
•    additional bed capacity.
•    extra ward staff to help reduce length of stay.
•    addition weekend trauma surgery capacity.

In November Swindon CCG received £1.208 million pounds for winter pressure.  This was not passed on to the Great Western Hospital and we have not heard in detail how it was spent.  We do know that the CCG’s board was told the money “has now been fully committed.”

No sooner is winter over than hospitals will have to turn to coping with the Better Care Fund (BCF - see the second article in this series.)  

The Fund will not start in earnest until 2015-16, but in the coming year it will begin to change how NHS money is used – with a switch of quite large sums away from acute hospitals to the joint CCG-Council BCF.  

Will the BCF be able to keep enough of the frail and elderly out of hospitals to allow the hospitals to reduce their capacity – as, with less funding, they will be forced to do. NHS bosses believe that the switch in funding will only work if hospitals can reduce their activity by 15 per cent – and yet hospitals, even without the pressures of winter, are at full stretch.  

Not only are they at full stretch as regards staff and patients.  They are also at full stretch as regards their budgets.  

For some full stretch has given way to over spend.  It was reported last week that trust hospitals are seeking £376 million in bailouts for the financial year just ending.  These hospitals are not yet being named, but they include five in the south of England which are asking for a total of £73 million.

Great Western Hospital is likely to break even.  With the Better Care Fund about to start gnawing at its funding, how long will it be able to stay out of the red?  And how loudly will GPs howl when services at the hospital are reduced because of the BCF?