Hospital discharge funding in England comes with strings attached, says King‘s Fund report

15th December 2023

One-off payments to reduce delayed hospital discharge ‘come with insufficient advance notice for effective planning’, forcing providers to resort to short-notice residential care rather than supporting patients at home, a new King’s Fund report has found.

The report, ’Hospital discharge funds: experiences of winter 2022-23’, looked in-depth at six health and care systems. The authors spoke to local authorities, integrated care system leads, acute trusts, Healthwatch and local care provider associations.

Commissioners and providers across each area ‘strongly criticised burdensome monitoring requirements’ and said funding was rarely available to prevent hospital admissions.

Areas did manage to use the funding to put services in place and support social care, but ‘were not confident they were spending funding as effectively as possible’.

The funding in question was provided in two tranches: the Adult Social Care Discharge Fund of £500m from the Department of Health and Social Care, and a further hospital discharge fund of £250m from NHS England. Each had different conditions, which were not known in advance, authors pointed out.

The report found that the six sites ‘did not all have a shared understanding of local causes of delayed discharges’ or ‘priorities for action’. Authors heard of more than 20 reasons for delayed discharge, although lack of staffing was a consistent theme.

The report also highlighted NHS England data which found that although many more patients were discharged home simply – seen in 85% of cases – compared with the predicted 50%. In addition, three times more patients needed 24-hour bed-based care on discharge (3%) compared with the predicted 1%.

Delayed hospital discharge a ’longstanding problem’

Simon Bottery, a senior fellow at the King’s Fund and co-author on the report, said: ’Delayed hospital discharge is a widespread and longstanding problem that affects thousands of patients, their families and loved ones. The underlying reasons for delays are often complex and vary between local systems, though workforce issues are often at the root of them.’

He added: ’Our analysis makes clear that the Department of Health and Social Care should only use short-term, ring-fenced funding on an exceptional basis and should ensure sufficient notice to sites so that they can plan for it. It’s welcome that this has been largely done for 2023/24 and 2024/25.

’It’s also clear that places should invest effort in developing shared understanding of discharge performance, the causes of delays and the priorities for action to tackle them, as we found that these were often lacking between system partners.’

NHS leaders may be forced to cut services without extra funding, NHS Confederation warns

26th October 2023

NHS leaders in England will be forced to choose which services must be cut unless the Government provides extra funding to cover the rising cost of industrial action, among other cost pressures, the NHS Confederation has said.

Strike action in England is estimated to have cost the NHS £1.4bn, compounding financial pressure brought by rising drug prices and continuing healthcare costs.

Both consultants and junior doctors took part in joint strike action last month for the first time in history.

With further strikes this winter set to push the cost higher, health leaders are already considering which services must be cut, operating under the expectation that they will need to reduce costs further, the NHS Confederation warned.

This would include restricting the number of extra beds they open this winter to manage expected higher demand, putting the NHS’ winter plan to introduce 5,000 more beds at risk of failure.

Leaders have also warned that progress on waiting lists may stall, anticipating that the NHS will miss Prime Minister Rishi Sunak’s pledge to reduce the size of the waiting list by March 2024.

That waiting list stood at 7.2 million when the pledge was made in January this year, but has grown by around 100,000 a month to 7.75 million.

Last week, it was reported that the Government has agreed to meet with the BMA Consultants Committee in the hope to find a resolution to the current pay dispute.

NHS Confederation chief executive Matthew Taylor said that both health leaders and health secretary Steve Barclay know the Government must ‘make an urgent decision on whether to cover the unplanned costs of strike action’ and other higher costs.

He added: ‘NHS leaders tell me that they are already having to take difficult choices every day on which services to cut back as they are not expecting any extra money to make up for the shortfall caused by the strikes, higher drug prices and pay costs being higher than the funding allocated at the start of the year. This will make an already difficult winter even harder to get through and we need the Government to face up to this risk.’

Responding to the Confederation’s statement, BMA council chair Professor Phil Banfield said that striking workers ‘are not to blame for the current financial crisis’ in the NHS, adding that it has been ‘years in the making’.

He said: ‘This is not about short-term solutions, but about long-term investment. Credible pay offers to bring about an end to disputes with doctors will help to ensure a more sustainable medical workforce.

‘It is crucial that the NHS has enough funding this winter and beyond so that instead of facing an “impossible choice“ about what care it can deliver, NHS leaders can feel confident about delivering the PM’s promise to the people about the future of our health service.’

A version of this story was originally published by our sister publication Healthcare Leader.

Cost concerns further delay NHS workforce plan

30th May 2023

The Government’s long-awaited NHS workforce plan appears to have been delayed as rumours circulate that it is too expensive.

According to deputy chief executive of NHS Providers Saffron Cordery, the plan, which was expected for publication today (30 May), has been delayed further. 

Speaking on BBC Radio 4’s Today programme, Ms Cordery said the plan will require ‘a very significant commitment of funding’ from the Government. 

Health secretary Steve Barclay declined to provide a deadline for publication during interviews over the weekend, according to The Guardian.

The workforce plan, which has already been delayed from last year, is expected to put forward solutions to address NHS understaffing, including expanding medical school places and potentially training apprentice doctors directly on the job.

Ms Cordery said: ‘We know that when it comes, it will be a very significant commitment of funding from the Government because what we’re talking about is setting out the number of training places and the number of staff that the NHS needs over the next decade or so.’

Of the delay, she added: ‘What everyone has been calling for, and what Jeremy Hunt committed to in his autumn statement last year and indeed talked about in the spring budget, was a fully-funded and fully-articulated workforce plan for the NHS. 

‘So I think that we are talking about something to do with the funding of this plan.’

The Times has also reported that disagreements over cost, which is believed to be in the tens of billions, have delayed publication of the plan.

A senior NHS source was quoted by the newspaper as saying that Prime Minister Rishi Sunak and chancellor Jeremy Hunt ‘can’t agree the financial commitment’ and that it ‘was all set to go this week and now the PM wants to run through it in detail’.

In March, reports of the plan revealed it would highlight that the health service is already operating with 154,000 fewer full-time staff than it needs and that number could balloon to 571,000 staff by 2036 on current trends.

The leaked report also said that without ‘radical action’, the NHS in England will have 28,000 fewer GPs, 44,000 fewer community nurses and an even greater lack of paramedics within 15 years. 

There have recently been calls from cancer professional organisations highlighting capacity and workforce challenges compromising patient safety and quality of care.

A version of this story was originally published by our sister publication Pulse.

Under the microscope: Essex Cardiothoracic Centre

11th May 2023

The Essex Cardiothoracic Centre celebrates its 16-year anniversary this summer, and with a recent funding injection leading to the development of a new cardiac catheter lab, the centre is gearing up to support more patients requiring thoracic procedures in the county.

The Essex Cardiothoracic Centre (CTC), located at Basildon Hospital and part of Mid and South Essex NHS Foundation Trust, serves a population of 1.8 million people across the county.

Each year, approximately 900 cardiac surgeries, 500 thoracic operations and close to 2,400 cardiology procedures are performed.

The CTC recently received £2.3m in national funding, which has been spent on a new 60 square metre cardiac catheter lab, expected to open in May 2023. The development will free up theatre space for thoracic surgery and increase lung cancer surgery numbers by a third.

Hospital Healthcare Europe caught up with Michael Catling, deputy director of operations for the Essex Cardiothoracic Centre and Mid and South Essex Cardiology, to find out more.

Why was the Essex CTC originally established?

Pre-2007, patients who needed heart or lung treatment had to travel to London as there was poor provision for these services in the county. The CTC was set up following a national requirement to increase capacity for cardiac surgery and specialist interventional cardiology procedures. The Department of Health selected Basildon as the site for a new Essex centre.

How will the latest investment improve thoracic services?

Our core capacity for thoracic surgery will increase by around 150 cases annually as heart procedures that were previously carried out in the hybrid theatre will be moved to the new cath lab, freeing up space.

We perform around 500 thoracic surgeries per annum of which around 180 are lung cancer cases. Demand has risen over the past five years, and until now, we have been reliant upon ad hoc additional lists, often taking capacity from cardiac surgery, which is not sustainable.

The ability to have an extra thoracic list every week in core capacity on the schedule without having to take any other service away releases the pressure and gives us the capacity to meet increasing demand in the coming years.

We provide a wide range of thoracic services for conditions of the lung, airway, pleura, mediastinum, chest wall and diaphragm. These incorporate cancer and benign disease with both open and minimally invasive approaches.

Why has there been an increase in referrals for lung cancer surgery?

The main driver is improvements in diagnostic services for lung cancer, including targeted screening, which increases the detection of early-stage cancers. Local community and hospital services are shortening diagnostic pathways and increasing access to diagnostics.

One of our communities within Essex was in the first wave of the national Targeted Lung Health Check (TLHC) programme that launched in November 2020. In April 2022, this rolled out to a second location and current plans are to extend this to all populations.

As of March, at least nine people in Southend had previously undiscovered lung cancer found and treated thanks to the TLHC. The same programme is also benefiting residents living in Thurrock. The latest data shows that 4,834 checks have been completed in Southend.

In addition, there has been a total of 1,827 CT scans and 127 referrals into hospitals after those scans to follow up care linked to cardiovascular disease, gallbladder, respiratory, breast, gastro, urology, liver and renal findings.

What facilities does the Essex CTC have?

A 16-bed cardiothoracic ITU, 32-bed cardiothoracic surgery ward, 28-bed cardiology ward, cardiothoracic theatre suite with four theatres including a hybrid IR theatre, cath lab suite including EP (electrophysiology) and structural labs, cardiac imaging including CT, MRI, special echo, outpatient suite, cardiac rehab department, pulmonary physiology department and overnight facilities for on-call teams and for relatives.

We offer a wide range of specialist tertiary services. Our higher volume procedures within cardiology are PCI (percutaneous coronary intervention), cardiac pacing, TAVI (transcatheter aortic valve implantation) and EP. Within the surgical service these are CABG (coronary artery bypass graft), AVR (aortic valve replacement), MVR (mitral valve repair), and complex aortic.

Additionally, over the past three years there has been a move from open lung surgery to minimally invasive lung surgery and our programme includes VATS (video-assisted thoracoscopic surgery).

How many employees does the CTC employ?

Around 600. This includes consultant cardiologists, surgeons, anaesthetists, thoracic histopathologists, specialist nursing teams, cardiac physiologists, clinical perfusion scientists, surgical care and operating department practitioners.

We also have UK training posts and international clinical fellows and have developed a strong national and international reputation for research within the centre. This is supported by our excellent relationship with the Anglia Ruskin University Medical School faculty with which we have a research fellow programme.

We have several colleagues with roles in external organisations and learned societies such as the British Cardiovascular Intervention Society. They contribute regularly to national and international events including presentations at Society for Cardiothoracic Surgery 2023, and by providing live-streamed cath lab cases for the 2023 physiology course at the Cardiovascular Centre in Aalst, Belgium.

How do you develop and retain your staff?

We’re very focused on doing what we do well, developing genuine tertiary services and particularly looking after our talented and passionate staff through training opportunities.

As a centre we are committed to offering excellent specialist training both to our own specialists and to related teams across Essex. The surgical team has delivered a programme of eight clinical simulation training events and wet labs over the past 12 months.

This has included two specifically related to the thoracic surgery service. In November 2022, we ran a lung resection day covering the teaching of both anaesthetic and surgical perspective with attendees from several other major tertiary centres in the UK.

In January 2023, we conducted a chest drain insertion day run jointly with the respiratory team, including hands-on simulation. Other courses in the past year have covered CABG, aortic and mitral valve surgery. This helps with staff development and retention.

What plans does the CTC have for the future?

As a specialist centre serving a large population and a number of local hospitals, our clinical plans incorporate continued development of specialist interventions and increased collaboration with local hospitals and primary care teams. This will include introduction of mitral TEER (transcatheter edge-to-edge repair), minimally invasive cardiac surgery, complex aortic surgery and thoracic port surgery techniques. We will be extending multi-disciplinary team working in chronic long-term conditions such as heart failure and atrial fibrillation through virtual ward models supported by latest technologies.

Our most important asset is our workforce, and we will continue to invest in training and education for our teams as well as developing new extended scope roles for advanced care practitioners.

View from Estonia: Urmas Sule

28th April 2023

Dr Urmas Sule, HOPE president, details how Estonia has weathered the significant challenges of 2022 and his hopes and expectations for 2023.

What were your key objectives and successes for 2022 in Estonia, and what were the main drivers for these?

In 2022, we moved from Covid-19 to an energy crisis and the uncertainty of war. Unfortunately, Covid is still very much present. Managing one crisis after another, and sometimes doing it simultaneously, proves a challenge for maintaining a reasonable balance of healthcare services for Covid and non-Covid patients. In my opinion, we have succeeded in guarding the patients’ interests and safety the best way.

Were there any specific facilitators that made these objectives more achievable?

During these difficult times, we saw how important it was to have smooth cooperation between hospitals and healthcare providers. An effective distribution of tasks and responsibilities was developed to protect patients’ interests in the best possible way.

We as hospital managers cooperate well with the Health Board, the Health Insurance Fund and the Government of Estonia. Continuous negotiations with the Government and the Health Insurance Fund about adequate financing of services and support for the health sector were necessary and proved very fruitful.

Our partnership with the Estonian Medical Association, the Medical Faculty of the University and the Health Care Colleges has been a big help in involving medical and nursing students.

Our main focus for 2022 was, and will always be, to protect our healthcare workers from burnout. This is not an easy task and needs good cooperation between all partners.

What did you perceive as the main barriers to reaching these goals?

Similar to other European countries, Estonia also faces the problem of a shortage of healthcare workers. Healthcare specialists are working for multiple employers. This is good for knowledge exchange, but is difficult to organise in a pandemic situation. Shortages have been a problem in Estonia for a long time, not just during Covid. The pandemic intensified the problem. Ensuring a reasonable division of labour and responsibilities between hospitals and other healthcare institutions has been a challenge.

But there are also other barriers, too. Political priorities have shifted from solving the healthcare crisis to an energy crisis and the effects of war. The primary focus has been improving readiness for emergencies in all areas. Helping Ukrainian refugees, providing them with social security and healthcare services is one of the important and ongoing challenges.

How did you anticipate overcoming any of these potential barriers?

The Estonian Government created a new crisis staff structure during Covid. This structure was adapted for the healthcare sector together with the Estonian Hospitals Association network. We have collaborated with the Estonian Health Insurance Fund to guarantee the best possible availability of healthcare services to all patients. This has been possible due to the prudent and flexible planning and financing of services.

To motivate employees, we have negotiated collective agreements in two-year increments. This has been a good opportunity to hear the needs and expectations of healthcare workers so we can do our best to try to meet those expectations and improve working conditions. Negotiations for the coming years are currently underway, and we will make all efforts to find a balanced agreement and retain the effective and trusting relationships among our social partners.

What measures did you use to assess whether these objectives were achieved?

The Health Insurance Fund measures the need for health services to lessen the treatment deficit. In collaboration, we have negotiated and agreed on the measures to reduce treatment deficits for non-Covid patients. We planned and introduced new services to prepare for Ukrainian refugees entering the healthcare system. But the biggest challenge for hospitals is the rapid and continuous rising costs of energy and other services.

We have monitored hospitals’ workloads and cooperated to ensure best use of all resources – especially the healthcare workforce – to create a flexible system that is prepared for new challenges.

How did these lead to improvements in patient care?

We have seen a rapid growth of the development and use of e-services and remote services and consultations in the healthcare sector in Estonia. There has been great development across many specialities – psychiatry, for example – during the pandemic. This has been possible due to the collaboration between hospitals, other healthcare providers and the Health Insurance Fund.

Because of the health crisis, we have increased infection control capacity and knowledge, not only in the healthcare sector, but also in society. A nationwide vaccination campaign has also alleviated the effects of Covid and the burden on the healthcare system.

What are the goals and challenges in Estonia for 2023, and are these contingent on the 2022 objectives?

We are negotiating the 2023/24 collective agreement with the Medical Association, Nurses Association and other trade unions. It is a challenge to achieve a balance between reasonable salaries and general pricing principles that include all input prices and guarantee adequate availability of patient services.

At the same time, our healthcare system has to achieve the best possible flexibility to be prepared for any possible crises. This seems like an endless and boundless task!