NHS crisis: Blair's biggest challenge

Trolleys in corridors are a part of the NHS winter

By BBC News Online's Maura Thompson

The Labour government's biggest test is imminent as health experts conclude that another NHS crisis in not just likely, but inevitable.

In recent days, as heads of royal colleges have signalled their concern and hospitals have dug out the 'no vacancies' signs, the Department of Health has tried to reassure.

But its decision to compile a "warbook" of potential NHS flashpoints this winter is an indication of top level concern that a new health crisis could spell political disaster immediately prior to a general election.

The fact is there are some things the government has no control over and so stories of lengthy waits on trolleys in corridors, cancelled operations and growing waiting lists are imminent.

Crisis points

Derriford Hospital, Plymouth restricts admissions to emergencies only

Belfast hospitals treat elderly patients on trolleys due to bed shortage

London hospitals warn nurse shortage threatens care

In fact in some parts of the UK, notably Northern Ireland, they have already begun.

Health Secretary, Alan Milburn, will send in hitsquads this winter to help those areas facing problems with staffing or bed shortages.

Such measures can be taken to reduce the scale of the forthcoming "winter crisis" but they won't prevent it.

The two biggest challenges facing the NHS in any winter are whether there are enough beds and whether there are enough staff to look after the people in the beds.

The health service has been trying to tackle a major shortage of staff for many years but it will be many more years before recruitment drives and training initiatives bring in the thousands of extra nurses and doctors it needs.

More beds

When it became clear that two decades of cutting back on bed numbers to make the NHS more efficient might have gone too far, new initiatives this year sought to reverse the trend.

In advance of this coming winter 343 additional critical care beds were planned and £63m allocated to intermediate care for older people.

At any time it is elderly people who occupy most of the beds in an acute hospital.

In the winter they are more vulnerable to flu and falls and when the winter crisis alarm is sounded it is generally because even larger number of old people have ended up in hospital.

Flu accounts for many problems

Opening intermediate care beds will, in theory, allow older people who would otherwise remain in hospital to be discharged to other services.

But, chief executive of the NHS Confederation, Stephen Thornton, says the number of older people remaining in hospital beds because there is nowhere for them to be discharged to is already "unusally high for October".

He says that, for this winter "the die has already been cast" and the NHS is bound to come under pressure, as it does every winter.

And, he added: "The most important thing the NHS can do now is to support and encourage its staff - those staff have commitment beyond belief and that will be the make or break factor."

Unknown severity

Health economists agree that all health systems face peaks of demand which put them under pressure, particularly in the winter.

Systems working efficiently simply don't have enough slack to allow them to cope when there is a sudden surge in admissions.

So, icy weather, colds and flu are just as likely to bring the health service in France, the United States or Australia grinding to its knees as the NHS.

Professor of Health policy at the University of Durham, David Hunter, warns the NHS is "close to meltdown" already.

The most important thing the NHS can do now is to support and encourage its staff

Stephen Thornton, NHS Confederation

"Partly that is because demand is rising, GPs are referring more, people turn up at their A&E departments and, despite what is said, we still have problems with 'bedblocking'."

He says the question is not whether there will be a crisis but where.

When there is talk of a winter crisis it is not usually a national one - local problems become magnified and the impression is that the whole system is struggling.

Local problems

Andy Bell from health thinktank, the King's Fund, says local problems may be because they are not managing staff or beds as well as other areas - but more likely it is just because they are unlucky.

"Winter pressures have become an annual event - a political event and if one part of the country is suffering because of a flu outbreak, then the NHS is having a winter crisis."

But he also believes that the government's centralisation of control is not likely to help this year.

"Hospitals are told they will be given more freedom if they meet certain criteria but the reality is they are so busy chasing their tails and meeting government targets there is very little room in the system. The whole NHS needs a break." he said.

Winter pressures have become an annual event - a political event

Andy Bell, The King's Fund

The NHS' biggest concern is how it will be hit by the flu, itself an inevitable part of winter - but an entirely unpredictable one.

The flu season officially starts in October and flu levels will always peak at some time between then and March.

The problem, according to the Public Health Laboratory Service, which monitors flu levels, is that there is no way of telling how high or when that peak will be.

The last official flu epidemic was 11 years ago, but, unlike other diseases, flu is not cyclical so there is no way of guessing when the next epidemic might be.

Yes, it could be this winter, though the fact that no new strains of flu have emerged during the recent Southern Hemisphere winter does bode well.

"If there is a completely new strain then we start to worry," said a PHLS spokesman.

"But the thing with flu is there is just no pattern. We don't know whether the rate will be 50 per 100,000 or 500."

It is that unknown that could spell crisis for the NHS this winter and disaster for Tony Blair.