Blog - winter pressures: wholesale cultural change is needed

In this blog, Visiting IPC Research Fellow Dr Melanie Henwood advocates for a wholesale cultural change to tackle winter pressures. Melanie joined a panel discussing this and wider issues around the need for a national independent living strategy for our ageing population, following a keynote lecture from Professor Roy Sandbach, at the Oxford Brookes University Healthy Ageing and Care network public lecture.

Grim stories of ambulances queueing outside hospitals. Long delays in responding to emergency 999 calls. Patients enduring hours on trolleys in corridors because of the lack of bed capacity on wards. Delays in discharging patients home from hospital. These are are all too familiar. This winter has seen such events intensify and reach record levels, but every winter bears witness to similar challenges.

The response from successive ministers and governments over many years has also often been predictable with a combination of criticism of the services which apparently must do better, and a menu of options including: improved patient flow; increased capacity; better streamlined discharge processes; more joined up working between health and social care, and greater focus on hospital admission avoidance and health prevention. None of this is new and none of it offers a magic bullet solution.

The latest Delivery Plan for Urgent and Emergency Care Services joins a litany of earlier attempts to unravel the Gordian knot, but does it offer any better prospects for success? There is greater emphasis on new types of care outside of hospitals, including ‘virtual wards’ and ‘hospital at home’ models. The terminology may have shifted, and the adoption of technology certainly expands the potential, but the concept is long-established.

Virtual wards have certainly expanded, the Department of Health and Social Care points to an increase of 50% to 7,000 hospital at home beds since last summer, with plans for an additional 3,000 "before next winter", and longer term ambition to support up to 50,000 people a month. These developments cannot be embraced uncritically, and there are some central questions that need to be addressed.

First is the matter of language and terminology, and this is not just about semantics. The power of neurolinguistics is well known, and reference to beds and virtual wards strike a dissonant note. At a time when the rhetoric is all about person-centred care and support, describing people’s own homes in this way is uncomfortable at best, and tone-deaf at worst. Does anyone really think of their own bedroom as a virtual ward? This is institutional and outdated language for supposedly new and innovative care models.

Second, there are reasons to be sceptical about approaches that are reliant on high-tech kit and solutions, while also claiming that there is no quick fix. The lure of technology can be seductive, but it is just another tool and should be used as a means to an end, rather than being revered as a ready-made answer. The need for people in virtual wards to be reviewed daily by video contact and other remote monitoring is not without significant ethical and moral questions. In addition, while emphasising that much of the pressure on health services comes from an ageing frail population, there is little examination of what technological approaches to hospital at home mean for caring for this cohort. People typically do want to be at home rather than in hospital, but not at the price of ‘care’ being delivered remotely and without the compassion of the human touch. Moreover, with the incidence of dementia and confusion among the older population, there are questions about the ability of people to engage with video calling, as well as their capacity to consent to home monitoring.

Third, the model of virtual wards is heavily contingent on support from family and unpaid carers, and while the delivery plan nods in the direction of supporting carers, there is nothing substantive to indicate what this might include. The additional pressure, stresses, and physical demands on carers – many of whom will themselves be elderly with their own health needs – are simply not considered. This omission is all the more important with the latest 2021 census data indicating an increase in the intensity of caring, with higher proportions of carers caring for more than 20 hours a week (and a fall in those providing lower levels of care).

Critical response to the winter pressures announcements has also come from local government, particularly concerned about the way in which social care has been portrayed as responsible for being the main cause of delayed discharges, while not being adequately engaged by government in developing solutions. The proposals for both short and medium term actions offered by social care partners also underline the necessity of ensuring that “community and bed based services to support recovery are available on an ongoing basis all year round and avoid an annual last minute search for solutions.” The local government perspective also highlights some key priorities including:

• Focusing on simple discharges for people without complex needs that can be achieved rapidly.
• Investing in voluntary sector support to increase capacity particularly around low-level support needs.
• Investing in support for unpaid carers and avoiding carer breakdown.
• Investing in therapeutic-led reablement to provide intensive short-term support after hospitalisation.
• Increasing care worker pay to address recruitment and retention challenges.
• Developing robust commissioning arrangements that avoid disputes between the NHS, councils and the care sector.
• Focusing on delivering effective transfers of care at the point of discharge.

This is advocating a wholesale cultural change that would break the recurrent winter pressure impasse and establish a coherent and integrated model across health and care. Many of these recommendations are grounded on the recent experience of Discharge to Assess, and the measures put in place during the Covid pandemic. It is vital to capitalise on this foundation and not to revert to the illusion that the answer to delayed discharges and malfunctioning urgent and emergency care is to be found in the mechanistic systems of patient flow that risk losing sight of the person.