Shifting from fire-fighting to sustainable solutions

Hospitals are stretched beyond belief. Short term solutions are plugging long term challenges. Patient care is suffering as a result. Our health care needs to move to the integrated ways of working envisaged by Accountable Care Systems if it is to be sustainable and cope with future winters.

The annual winter crisis

Over the last few years, we have seen the NHS struggle against the ‘winter crisis’. This year is no exception. Recent news reports highlight that patients are dying in corridors and ambulances are queuing round the block, while NHS staff struggle with the impossible balancing act of demand outstripping hospital bed supply.

A&E’s four hour wait target is widely used as a pressure indicator for how stressed the system is as a whole. In December, hospitals saw just over 85% of patients within that time. The target is 95%.

In the first week of January 2018 there was a point where 97% of hospital trusts in England had an unsafe number of patients on their wards.


More money alone won’t work miracles

The annual rise in government spending on health has dropped significantly since 2010. So while it’s true that funding has increased, it’s just not as much as we’re used to – and not enough to fix the problem. However, it is unlikely that if the Government changed tack and significantly increased funds that it would wholly fix the problem, although it might relieve some immediate headaches.

The health care system still suffers from siloed working; out of hospital, social care and acute services are not set up to work effectively together. Their digital and financial infrastructure is disjointed and there is a culture that does not always support working across departments or organisational boundaries. This causes inefficiencies and poor advance planning over winter.

Bed space is increasingly taken up with patients who would be better cared for in the community. Patients experience difficulties accessing primary care, and seek emergency care for their non-urgent conditions, or delay their care until it is a medical emergency. The siloed working can result in patients being passed from pillar to post across the system, where accountability for their care is not owned by any one organisation.

The benefits of moving to Accountable Care Systems

We are pleased to see that the NHS is moving from a focus on individual organisation performance to looking at whole systems providing integrated care across populations.

These Accountable Care Systems (ACS) integrate across the acute, out of hospital and social care sectors – and are accountable for the health outcomes of the population in their footprint. The recent addition of social care to the Secretary of State for Health’s portfolio demonstrates this transition all the way up to the Government.

This is an exciting transformation in the way that the NHS cares for patients. Importantly it empowers local leaders to take control of funding and performance in their areas.


Potential advantages of this model include:

  • incentivising a more integrated approach to caring for long term conditions, including ensuring that patients’ care packages are meeting their needs and are effective in supporting them to avoid emergency visits to hospital
  • a more coordinated approach in planning to manage the increases in demand during winter across hospitals, primary care and social care
  • reduced pressure on A&E, and increased use of re-directs into out of hospital settings
  • increased focus on prevention – with more accountability and incentivisation for it to be effective
  • smoother and more coordinated provision across boroughs within a footprint
  • overall better patient experience and health outcomes.

With so much potential, this approach needs to work. We believe there are six fundamental elements that need to be in place for an ACS to be successful, and for winter to avoid crisis.

  1. The right population footprint built around the patient flows of the population, and not necessarily based on historic NHS boundaries. Transport networks are often a key determinant of this in creating flows that are not always concentric around a single centre.
  2. A formal legal structure with accountability and funding calculated to meet the needs of the population in the most effective way. This might include increasing funding for social care for the provision of more cost effective community based care.
  3. Digital integration across services so that organisations can effectively integrate, removing inefficiency and improving clinical outcomes and patient experience.
  4. Culture change to encourage bigger picture thinking across a whole populations’ health needs. This will require a deliberate programme of interventions to achieve, requiring the whole system (including patients’ themselves) to pull together in order to be jointly accountable for outcomes.
  5. Give the time to plan by taking a leaf out of the military’s book and using the 1/3 – 2/3 rule of planning, so that NHS national / regional bodies spend no more than 1/3 of the time planning the winter strategy, and enable the ACS to spend 2/3 of the time planning their roll out on the front line operations.
  6. NHS England and regulators to align to the new model ­– ACSs will need be to trusted and empowered by the National and Regional bodies, as we’ve outlined before in our article Trust the Trust. It would also be beneficial to align regulators to this new model, so that their scope of assessment is not just on an organisation’s quality of care provision, but also how they are working to support the objectives of their ACS.

Make the shift to sustainable solutions

If crisis is to be averted, systems need to be empowered and accountable for their local populations, with a focus on integrated working to improve patient outcomes and experience.


Grace is a principal in our Health Team. She has worked across a broad range of the health systems, with clients including NHS England, Sustainability and Transformation Plan (STP) footprints, Clinical Commissioning Groups and NHS trusts. Grace is passionate about supporting organisations to design and deliver change in order to provide a better, safer and more sustainable service for the future.