‘Winter feels a scary place’: Bolton hospital braced for zero capacity

In a cubicle at Royal Bolton Hospital, Zoe Grech was waiting to undergo thyroid removal surgery. When, back in May, her consultant told her that she needed the operation, she expected speedy treatment. “I was told I was put at the top of the list because it’s affecting my breathing,” she said.

The 39-year-old nursery worker has spent the intervening period in limbo, waiting for a slot that has taken six months to arrive. She suffers from anxiety, a condition that has not been helped by the wait.

As the UK health system faces the triple threat of record backlogs, a winter Covid and flu wave and historic strikes, the NHS’s own vital signs are giving cause for alarm.

Grech is one of at least 5.5mn people in England waiting for hospital treatment, a potent symbol of a system in crisis. Almost 390,000 people have been waiting more than a year — a figure that in the eight years before the pandemic at no point exceeded 4,000.

Health leaders have urged the chancellor Jeremy Hunt to protect spending on health when he delivers the Autumn Statement on November 17. Last month, NHS finance director Julian Kelly revealed the service was facing a funding black hole of around £7bn next year; services including cancer, mental health and general practice could suffer, he said.

Jennifer Dixon, chief executive of the Health Foundation, a research organisation, said the pressures on the NHS were the greatest she had seen in her 40-year career.

The last decade, in which the service has felt the lash of austerity, has “just been so lean that we haven’t been able to build up, in particular, the workforce that’s needed but also the capital which can be labour-saving and the new technologies which will enable the NHS to be even more productive than it is,” Dixon added.

If high inflation persisted, without extra funding in the Autumn Statement “the NHS is likely to face three years of falling spending power, unprecedented in its history”, she added.

The UK is already an international laggard, investing around 0.3 per cent of gross domestic product on capital spending in healthcare, well below peer countries. Britain has two hospital beds per 1,000 people, fewer than any other wealthy western nation, and far fewer MRI and CAT scanners than its counterparts.

The consequences can be seen in Bolton, north-west England, where overwhelming demand from a growing and ageing population, against the backdrop of an outdated estate, is straining resources to the limit.

At the end of last month, the trust was forced to declare a “critical incident” after being overwhelmed with “excessive” numbers of patients waiting in accident and emergency, according to Tyrone Roberts, chief nurse. Such steps were usually associated with the difficult winter months, not a mild October, he said.

Covid cases are at manageable levels, with 54 patients suffering from the disease, down from a peak of 171 in January. But the impact of the pandemic continues to be profound. People seeking care are generally sicker, he said, “maybe because they’ve stayed away and have now come forward. Or they’re more frail, because they’ve been waiting [so] long.” The workforce, too, is burning out after two and a half years of unremitting pressure: “They’re human beings and they get tired”.

One story of the past two years has been lengthening ambulance response times in part because of difficulties in offloading patients at hospitals owing to a lack of beds.

The impact can be seen in ballooning A&E waits. In England 43,000 people spent more than 12 hours waiting for a bed in October after a doctor decided they required admission. The equivalent figure in October 2019 was 729.

In Bolton hospital’s accident and emergency department, there is no disguising the extent of the challenge. Imran Khan, urgent care lead, said at the start of the recent critical incident “we had 90 patients. Our [major injuries and illnesses] department is only built to accommodate 21 patients”. At one stage there had been a 50-hour wait for a bed, he said.

Steps such as repurposing other parts of the emergency department to treat less urgent patients allowed it to weather the storm. “We’ve managed to keep everybody safe,” he said.

However, the department has had to adjust its ways of working to cope with patients coming straight to A&E, unable or unwilling to seek an appointment with their GP. “I always call it the kind of Amazon Prime model of healthcare: people want something and they want it now,” Khan said.

Bolton is working hard to cut its backlog for non-urgent treatment. More than 20 per cent have been on the hospital’s waiting list for a year or more but the number of 18-month waiters has fallen to 136, from 720 a year ago.

Workforce shortages loom large, however. Niamh Brockenshaw, matron for theatres and day care, said each morning the big question is whether they have sufficient personnel to carry out the operations scheduled that day, alongside emergencies.

Sometimes cancellations, which staff are desperate to avoid, can only be averted by employees working beyond contracted hours or carrying out more junior roles to fill rota gaps, she said.

“As an organisation we’re very much working on the free goodwill that we have with our teams,” she said. The hospital has taken a novel step to increase the pipeline of new employees. Bolton NHS Foundation Trust is collaborating with the town’s university, a local college and the council to offer a direct route into health and social care by creating up to 20,000 new jobs and apprenticeships.

The trust has succeeded, through targeted investment, in clearing its backlog of endoscopies, with waiting times now at pre-Covid levels. But this is a rare bright spot. The impact of a threadbare social care system has left Bolton, like so many hospitals around the country, struggling to discharge even medically fit patients. In England, 14 per cent of beds are occupied by patients who no longer needed to be in hospital, a record high.

At Bolton, Cheryl Thompson, reactive care lead, said typically around 100 beds each day, out of a total of 578, are occupied by patients who could go home, even though the composition of this group shifts constantly, as she and her team succeed in finding community or family support for patients.

She manages staff from the local authority as well as the hospital, a sign of how health and social care services are working ever more closely together to ease the strain.

Her fear, however, is of getting to a place “where everything just stops . . . where we have no capacity anywhere”. Contemplating the months to come, and the demands she and her team will face, she added: “I would say winter feels a scary place.”