Secularism is on the rise in the UK. In fact, as of last year, the British Social Attitudes Survey^[1] reported that 52% of the population identified as having ‘no religion’. There is however, one monolithic organisation that continues to enjoy unwavering support and devotion from the British public - “our NHS”. This reverence has made the NHS the quintessential political football, most recently exemplified by the Tory government’s rushed announcement of 40 new hospitals.  A policy which has become a defining mantra of Boris Johnson at Cabinet meetings.^[2]

Whilst this promise may have titillated the electorate, students of health policy met its announcement with a collective groan. Last year, for the first time, the NHS had been given a mandate to design a strategy which looked beyond the traditional 5-year electoral cycle following the publication of the “Long Term Plan”. This Plan, buoyed by an additional funding commitment of £20.5 billion, set out an ambitious agenda to transform the NHS from its traditional, reactive approach to a person-centred system rooted in prevention.

Given this context, we can see why planning a large expansion of acute capacity might not be the most congruent approach. Whilst it is difficult to argue that our crumbling hospitals are not worthy of investment, with some sites having over 40% of their estate deemed ‘not fit for purpose’,^[3] there is an air of ‘treating the symptoms, not the cause’. 

A sticking point in the UK’s healthcare system, and a major contributor to hospital bed occupancy rates rising above safe levels, is the issue of Delayed Transfers of Care (DTOC). DTOCs are bed days incurred by patients that are medically optimised but, for a plethora of reasons, are still occupying an acute bed.

Bed days in England attributable to DTOCs has averaged 4.6% of total bed occupancy over the last 4 years,^[4] and whilst this in itself seems large, the number of actual bed days occupied by medically optimised patients is likely to be 2-3 times that figure.^[5]  It therefore seems to follow that, if we were to solve the DTOC issue, there would be an immediate release of around 10-15% of acute capacity, without any need for new estate - so what is the root of the DTOC problem?

The reasons for delay largely fall into one category - a lack of “out-of-hospital” provision, which could be met in several ways: a residential or nursing home; extra care housing; intensive rehabilitation provision; and home-based packages of care. The top three reasons for DTOCs since records began have consistently been concerned with procuring capacity in a lower acuity setting.

Creating enough capacity in the intermediate care sector to solve DTOCs would however, not be a panacea as the issue does not just affect people leaving hospital - many patients are better served by not being in an acute setting in the first place. A 2013 study by Blunt found that roughly 1 in 5 emergency admissions to hospital could have been dealt with in a lower acuity setting.^[6] Unnecessary hospital admissions are not only bad for system efficiency, but they are traumatic for patients and objectively worse for long-term health outcomes, with the risk of hospital-acquired infections and an increased trajectory of functional decline in frail and elderly patients.

The issues with intermediate care capacity are compounded further by the workforce crisis in health and care, which while stark across the whole sector, disproportionately impacts community care.   

When the ‘40 new hospitals’ commitment was made, we lived in a vastly different world. The COVID-19 pandemic has seismically altered everyday life in the UK and has brought the NHS into sharper focus. It would be tempting, given the ostensible lack of capacity in the acute sector, highlighted by the implementation of the Nightingale hospitals, to cede to the Health Infrastructure Plan and advocate for increased acute capacity, but this does not tell the full story.

The Nightingale project has in fact provided further evidence that acute capacity isn’t the issue. Most of the sites are being used as step-down wards and the one that isn’t, the Excel Centre in London, sits worryingly under-utilised. Just 19 of the potential 3,650 beds were occupied over the Easter weekend,^[7] as hospitals flexed their existing capacity to accommodate the surge in demand for ICU beds.

COVID-19 offers a unique turning point for our country. Following the theme of needless war metaphors the pandemic attracts, it seems that just as the Second World War gave us the NHS, we must ensure we do not squander the chance that this ‘war’ provides to re-evaluate it. In the second part of this series, I will explore how we can ensure we use this opportunity to create a refreshed NHS that is fit for the future.

Charlie is a public sector strategy consultant and has lectured as a guest at the University of Manchester. He writes in a personal capacity.

^[1] Curtice J. British Social Attitudes Survey 2019 [Internet]. BSA 2019 [cited 2020 April 25]; Available from: https://www.bsa.natcen.ac.uk/media/39363/bsa_36.pdf

^[2] Duncan C. Boris Johnson makes entire cabinet recite debunked campaign lies about the NHS in unison [Internet]. The Independent 2019 [cited 2020 April 25]; Available from: https://www.independent.co.uk/news/uk/politics/boris-johnson-nhs-campaign-lies-cabinet-meeting-ministers-hospitals-a9250011.html

^[3] Anandaciva S. Does the NHS really have a new strategic health infrastructure plan? [Internet]. The King’s Fund 2019 [cited 2020 April 25]; Available from: https://www.kingsfund.org.uk/blog/2019/10/health-infrastructure-plan

^[4] NHS England. DTOC Statistics [Internet]. NHSE 2020 [cited 2020 April 25]; Available from: https://www.england.nhs.uk/statistics/statistical-work-areas/delayed-transfers-of-care/

^[5] Edwards N. What's behind delayed transfers of care? [Internet]. Nuffield Trust 2017 [cited 2020 April 25]; Available from: https://www.nuffieldtrust.org.uk/resource/what-s-behind-delayed-transfers-of-care#dtocs-the-tip-of-the-iceberg

^[6] Blunt I. Focus on preventable admissions [Internet]. Nuffield Trust 2013 [cited 2020 April 25]; Available from: https://www.nuffieldtrust.org.uk/research/focus-on-preventable-admissions

^[7] Dunhill L. Nightingale largely empty as ICUs handle surge [Internet]. Health Service Journal 2020 [cited 2020 April 25]; Available from: https://www.hsj.co.uk/service-design/exclusive-nightingale-largely-empty-as-icus-handle-surge/7027398.article