Thursday, 15 January 2015



A surge in hospital activity over winter months is predictable, yet this winter we face unprecedented challenges at the frontline. There is much talk of an A and E (Accident and Emergency) ‘crisis’ but A and E represents only one of several interfaces within the healthcare structure.  Consider the following simplistic bathtub model of hospital flow to look at how primary care, secondary care and social care interface with each other.

1. The hospital is a bathtub. If the size of the bathtub reflects the number of hospital beds, we have in the UK the smallest bathtubs in Europe (half as many beds per head of population compared to France; see here to compare).
2. The water level in the bath is determined by patient flow into the hospital (via the tap) and out of the hospital (via the outlet pipe). The tap in turn is determined by a number of factors including the following: access to primary care, telephone advice (NHS 111), and patient choice (to attend the ED rather than see a GP).

3. Flow out of the hospital on the other hand depends on patient recovery, access to rehabilitation beds and social care.

4. There is an additional re-entry circuit: when flow through the backdoor is obstructed and social care is unable to cope, outflow is diverted back to inflow (the hospital readmission).
Recent changes to the NHS have had an impact on this model at both ends. 

Recent changes mean that the tap has been turned to full. The number of district nurses, who play a crucial part in keeping people out of hospital, has fallen by 40% over the last decade. General practice, the jewel in the crown of the NHS, is also vital to keeping people out of hospital but now being stretched to breaking point. Recent changes following the Health and Social Care Act 2012 have distracted GPs from their clinical work and led to older GPs seeking early retirement.  Patients are finding it harder to access primary care and opt instead for the emergency department (ED).  NHS 111 is sending larger numbers of patients to the ED (see below).
At the same time, the flow of water out of the bath is being blocked. Social care cuts have made it harder to get patients home.  Many smaller cottage hospitals, rehabilitation facilities, and nursing homes have been closed.
At the easiest of times, hospitals are run at 100% capacity for maximum efficiency. But open the taps to full by overwhelming primary care, then plug the outlet pipes by cutting social care and rehabilitation beds, and the bathtubs of the NHS, no matter how efficient, will overflow when winter arrives.
Vinod Achan
Vinod Achan is a Consultant Cardiologist and Consultant Lead for Emergency Angioplasty at Frimley Park Hospital (now part of the Frimley Health NHS Foundation Trust)