Breaking point: Inside the NHS’s looming crisis

Special Report: Ministers say the NHS still isn’t facing unsustainable pressure. But with Covid cases rising unchecked and demand on hospitals surging, doctors, nurses and officials tell Shaun Lintern the health service is facing its worst winter ever

(PA)

The NHS faces its hardest winter yet as soaring coronavirus cases combine with a surge in A&E demand and a health service brought to its knees by 18 months of unrelenting pandemic pressure.

While ministers including health secretary Sajid Javid have claimed the Covid resurgence has not put unsustainable pressure on the NHS, doctors, nurses and health officials from across the country have told The Independent the mounting crises on several fronts mean the health service is facing a very real catastrophe.

With daily coronavirus infections at 50,000 and the number of patients admitted to hospitals each day close to 1,000, the chair of the government’s Covid modelling committee, Professor Graham Medley, said the country could be “three or four weeks away” from a serious problem if the rise remained unchecked.

Leaked modelling shows that A&E departments also face dangerous levels of crowding in coming months, with 60,000 more patients a week.

As one NHS chief suggested Mr Javid was living in a “parallel universe”, The Independent found:

• The Royal College of Emergency Medicine is warning this will “likely be the hardest winter the NHS has ever had”;
• Intensive care beds up and down the country are lying empty because of a lack of nurses, according to the Intensive Care Society;
• A sick two-year-old girl was forced to sleep on two chairs pushed together in a waiting room during a 14-hour A&E wait;
• One hospital is to begin turning away non-emergency patients at A&E from Monday;
• A leaked survey of more than 114 NHS surgical teams found two-thirds have reduced operations with almost a fifth unable to do hip replacements;
• The military has been called in to support three hospitals in Scotland as the area moved to a “black alert” level; and
• NHS data shows the patients are staying in hospital significantly longer because community services cannot be found to look after them.

Graham Medley, chair of Spi-M, the government’s scientific committee modelling the spread of Covid-19, told The Independent that, while there was huge uncertainty about Covid-19’s progression, the situation was not far from a tipping point.

The professor of infectious disease modelling at the London School of Hygiene and Tropical Medicine said throughout the summer the country had been below expected levels of infections and hospital admissions, but added: “Clearly, if they keep going up then we move into ‘expectation’ and then potentially we go over ‘expectation’, but they have to keep moving up, and at the current rates of increase, we’re about three or four weeks away from getting into the kind of areas that might well be concerning.

“Double what we’ve got at the moment is going to cause more than double the problems and at the current rate, if it doesn’t change, we are three or four weeks away from doubling.”

A key concern for ministers is the threat of waning immunity among vulnerable groups who were jabbed early on – many are reaching the point when it is thought vaccine protection diminishes. This puts them more at risk at a time when, according to the latest Office for National Statistics survey, more than a million people are infected.

Prof Medley added: “The other big driver is behaviour, what it is that people do, and that of course is unpredictable and that's where a lot of the uncertainty comes from.

“If things go badly wrong, a lot of mixing and waning goes much faster than we expect, then things could still turn out badly.

“I’m relatively optimistic. We are seeing an increase now, but I think that immunity will win out.”

On Friday, minutes from the Sage group of government advisers showed scientists warned ministers to start preparing for their “plan B” to combat increased spread now. Professor Medley said: “I think it’s absolutely true the science is quite clear that acting early certainly reduces the risk of having to act harder later.”

The latest modelling summary, published on Friday by the Spi-M committee, said: “It will take both a rapid increase in transmission rates and repeated waning of protection from vaccination to lead to hospital admission levels in the order of magnitude of those seen in January 2021.”

But it added: “Many of the scenarios modelled have an extended period of time with a high number of hospital admissions. Even if peak admission levels remain well below those of January 2021, this could still put health and care settings under significant pressure, particularly if this coincides with high numbers of patients with other respiratory infections, which have not been modelled.”

The weekly admissions to hospitals have now reached a seven-month high and comes on top of a range of problems the NHS is already facing irrespective of Covid-19.

‘The hardest winter’

More than 160 patients crowded into Royal Stoke University Hospital A&E department on Wednesday night as footage emerged of ambulances stacked outside the hospital waiting to hand over patients. This scenario has been repeated across the country throughout the summer.

Patients in Plymouth Hospital on Wednesday night faced a seven-hour wait to see a doctor and in Cornwall, where bosses have declared a critical incident this week, one patient waited with paramedics for over 13 hours to be seen in the hospital. A&E patients in Preston are regularly facing almost 50-hour waits for a hospital bed.

The Independent has seen leaked internal modelling from NHS England showing the surge in A&E attendances could get even worse, with the prediction for April of 350,000 patients a week across the nation – 60,000 a week higher than in June.

The NHS England document said such increases would mean an extra 60 patients a day at a typical 24-hour A&E unit, with 15 to 20 of them needing a bed, warning of a “significant impact” on crowding and a knock-on effect on routine surgery.

Modelling forecasts from NHS England outlining the expected rise in A&E attendance ( )

Dr Katherine Henderson, president of the Royal College of Emergency Medicine, told The Independent: “Even before the pandemic, emergency departments were struggling, a consequence of under-resourcing. Now we are going into what will likely be the hardest winter the NHS has ever had.”

Some hospitals are now planning to turn away patients who do not have life-threatening illnesses or injuries. From Monday, Arrowe Park Hospital, in Merseyside, is to trial a system where any non-emergency case will be sent to alternatives such as walk-in centres, GPs or pharmacies. After a 5 per cent rise in A&E attendances in the first eight months of 2021 compared with 2019, the trust said it hoped the stance would cut long waits.

Data seen by The Independent from West Midlands Ambulance Service shows there were 5,752 ambulances waiting longer than 60 minutes to handover patients to A&E staff at hospitals across the region in September. Ambulance handovers are meant to be completed within 15 minutes so paramedics can get back out to waiting 999 emergencies.

Heartlands Hospital, in Bordesley Green, Birmingham, was the worst site for handover delays with 629 delays lasting more than an hour. Royal Stoke Hospital was second worst with 618 delays.

‘Everyone is in their own little nightmare’

David Barker, aged 36, from Stoke-on-Trent, knows exactly what an overwhelmed NHS looks like. His two-year-old daughter Violet had to sleep on two chairs pushed together in the A&E department at Royal Stoke Hospital earlier this month.

The toddler had been taken to hospital after she was left unable to eat or drink and struggling to breathe. Mr Barker said he and his daughter endured a 14-hour wait in A&E on 15 October before Violet was eventually given a bed and treatment in the children’s assessment unit.

He said: “They kept saying ‘we are trying to find you a room’ and we had been there for 12 hours by this stage. So in the end I just pushed the two chairs together to make a makeshift bed so Violet could sleep.

“Even though the NHS is amazing, and something to cherish, its processes are broken. You could see that the staff were under pressure from all avenues. You’re in that cubicle and you can hear all the conversations around you, it’s like everyone is in their own little nightmare.”

Violet Barker asleep on a makeshift bed at Royal Stoke Hospital last week ( David Barker)

Mr Barker said he had taken a photograph so people could understand and see for themselves how bad things were. Violet was allowed home the next day after treatment.

Enabling the “flow” of patients out of A&E and on to wards is a vital aspect of any hospital’s daily operation. But they have to have the beds available.

More than 8,000 beds are occupied with Covid patients as hospitals have had to restructure wards to keep non-Covid patients free of infection. This has meant more bed closures.

‘There are empty intensive care beds up and down the country’

During the height of the pandemic, NHS intensive care units were on the front line in the fight against Covid-19 and saw services rapidly expanded, sometimes doubling or tripling their usual number of beds. Intensive care nurses were stretched across multiple patients.

At the time, experts warned the critical care nursing workforce was working at unsustainable levels and were mentally and physically exhausted by their experiences of Covid-19.

Now, many of those staff have left for career breaks, less-demanding roles or, for those who had moved to the UK, to go home. Hospitals have then been left with beds for patients but no nurses to look after them.

One London hospital consultant said the shortage was severely affecting the number of operations that could be carried out.

Dr Stephen Webb, president of the Intensive Care Society, and a consultant at the Royal Papworth Hospital, Cambridge, said: “Workforce is the biggest pinch point in critical care at the moment. The result is you can have a 15-bed unit but you may only be able to open 10 or 12 of those beds.

“There are empty intensive care beds in organisations up and down the country because we don’t have the nurses to staff them. We’ve heard from members in every region of the country where beds are not open.

“It is heart-wrenching. These are cancer surgeries, cardiac surgeries and other operations that are not happening. We are not able to deliver the care we need to.”

Dr Webb added the situation meant the winter of 2021 for the NHS would not be normal: “We are still dealing with a disease that didn’t exist before, taking up 20 to 30 per cent of all ICU beds.”

He said the health secretary’s description of pressure as not yet “unsustainable” was disappointing, adding: “For those of us who are on the ground this does feel like unsustainable pressure.”

The strain on intensive care units can be seen in NHS data showing the number of times critically ill patients are moved between hospitals because services are struggling.

From 1 May to 15 October there were 343 hospital transfers for patients for this reason.

When hospitals lack these beds they cannot provide routine surgery for patients with cancer or needing hip replacements who will need recovery time in intensive care. Already this year, hospitals have cancelled large numbers of operations including for life-threatening cancers. The waiting list for routine treatments is now a record 5.74 million.

In Lanarkshire this week health chiefs said the Scottish region was moving to its black alert level after what they said was “critical occupancy levels across its three acute hospitals”, with operations including cancer procedures cancelled. The military has been brought in to support the three hospitals.

The message added: “There are more patients than available beds and staff have already been redeployed across the whole system to open new inpatient areas. This is against a backdrop of increased clinical demands across our entire systems of care, higher levels of staff sickness due to the Covid-19 pandemic and national staff shortages.”

‘This is catastrophic’

A survey by the British Hip Society, at the request of the NHS and British Orthopaedic Association, asked 114 NHS units if they had returned to pre-pandemic levels of surgery, with a focus on total hip replacement surgery.

The results on Friday, shared with The Independent, found 18 per cent of units were unable to offer patients hip replacement surgery at all, with 66 per cent of units working at reduced levels of activity. Only 16 per cent were back to pre-pandemic levels of operating.

When asked what the biggest reasons were for not being able to carry out surgery, the survey found a lack of theatre staff or bed capacity was the main cause in 57 per cent of teams.

One hospital surgeon told The Independent: “This is the worst I have seen things in almost 20 years. This is catastrophic.

“We would normally have two full wards and a smaller ward but we lost the two wards in the summer and I can’t see us getting them back. We have been doing day case surgeries because they don’t need an intensive care bed and on the data I look like I am being very productive, I am actually running out of day cases. But the highest priority patients we are really struggling to do because we don’t have the beds they need.”

The surgeon added theatre nurses had been redeployed to critical care, prompting some to resign.

Patients stuck in hospitals

Another crucial factor for hospitals continuing to function is a steady stream of patients being discharged – sent to their home, into care or services such as a hospice.

But while there has been new investment in discharge processes during Covid, services are not available in some parts of the country.

On Friday, the Care Quality Commission warned some care homes and homecare services were closing because they couldn’t recruit enough nurses. In some areas this means patients are stuck in hospital because there are not the services they need in the community.

The number of district nurses in England has halved since 2010 and vacancy rates in social care overall have jumped from 6 to 10 per cent. Tracy Allen, of Derbyshire Community Health Services Trust, said they had more people waiting for care than at any point in the previous 12 months, with similar issues across the country.

Data from NHS England showing the number of long stay patients in hospitals ( )

She said she was concerned that focusing on discharges from hospitals meant services that helped patients look after themselves and avoid admission to hospital in the first place would be cut back.

NHS England data on hospital beds taken up by long stay patients shows a slow rise in numbers since May last year, meaning fewer and fewer beds available for surgery or emergency patients while numbers turning up at A&E are at record highs.

According to the data, the number of 21-day, 14-day and 7-day-long stay patients have all increased, with the latter category increasing by more than 10,000 since last year.