The real symptoms of a tough winter

Winter has arrived, as we knew it would, but are our hospitals ready for the extra workload this season inevitably brings?

EACH YEAR demand for healthcare rises in the winter months. The whole health service feels the pressure, but it’s evident most dramatically in acute hospitals.

In worst case scenarios, the annual “winter crisis” brings extensive bed blocking, long trolley waits, care cancellations and longer waiting lists.

Former English health secretary Alan Milburn said that for the NHS “winter begins in July and ends in June”.

The reality is that managing fluctuating demand and capacity is now part of normal working activity for healthcare providers. This is reflected in the way the HSE Winter Initiative programme has evolved into an ongoing improvement approach.

The areas it targets for improvement – such as discharge planning – are now a focus all year round, not just when the mercury drops.

This makes a lot of sense. A naive observer might assume hospitals discharge patients on the day they are ready to leave. But half or more of patients are not discharged then.

Booked arrivals, however, are often told to arrive early and are admitted to a bed first thing in the morning. That makes two groups of people occupying beds, most of whom do not need to be there.

A hospital with a disciplined approach to admission and discharge could free up beds every morning and would know where every patient was; when they were due for discharge; and when booked patients were due to arrive.

It would be able to respond quickly to surges in AE attendance or outbreaks of infection, and reschedule arrivals or expedite discharges to create space. A hospital not in control will not have the management levers to do this.

Therefore, getting the basics of capacity management right is essential to enable the system to cope in times of high demand such as winter and . It is also essential to manage the system efficiently at other times.

So is dealing with the known, imminent winter demand increase just about getting the basics right? Or are there specific factors that require exceptional measures to be taken?

A convergence of new and old pressures is setting the scene for an exceptionally challenging winter for our healthcare system.

A proportion of the beds in several of our larger hospitals are already “blocked” before winter has even begun – there are inpatients who are medically fit to be discharged but the required next step in their care, such as a nursing home bed, is not available. This reduces the number of beds available to hospital management to deal with new winter demand.

Flexibility of the bed pool is reduced by the need to ensure patients with healthcare-acquired infections are cohorted.

There is the prospect of a second wave of swine flu. A worst case scenario pandemic would create significantly greater demands on the health service than a severe flu season.

The finance will not be available to resource “release valves” such as additional beds and staff. Rather, these resources are likely to be constrained or reduced. Hospitals may not have the resources to maintain the levels of bed capacity they know are required to deal with surges.

In this scenario there is little space for dealing with peaks in demand and no room for error.

Coping successfully with this winter scenario necessitates integrated winter planning in a new and broader sense.

This is not just within the hospital but involves primary and community care, public health professionals, local councils, the voluntary sector, the media, patients and the wider public, too.

Linking community and home care capacity to the hospital system in planning allows for smoother, timelier flow of patients and provides more patient placement options when pressures start to build in the acutes.

The winter illness prevention agenda includes elements as diverse as cold weather warnings and fuel supply to flu vaccines and public health nurse check-ups – extending the planning team far beyond the hospital.

There is also an onus on the public to consider our individual healthcare footprints – why we access care and where we access it – as well as how we support those in our community who may be vulnerable in winter.

While several of the symptoms of a tough winter present in the acute hospital, coping with winter demand requires more than good management of acute beds.

Planning and operating as a community in this broad sense stretches the boundaries of traditional healthcare planning, but surely must make more sense in preparing for this winter.

• Síle Ryan is a managing consultant with PA Consulting