The seasonal spike in the number and acuity of patients often means that performance across the NHS slips over winter. In the past, the NHS usually begins recovering performance against key constitutional standards through spring. However, what we have not seen this year is any easing of operational pressures, with winter conditions and performances continuing in to March.
Data at the end of March showed performance against the A&E four-hour waiting time target at 84.6% and performance for major A&E departments (type 1) at 76.4% - both the worst levels since the data collection began in 2010.
This winter has been described by many on the frontline as the toughest they have faced. So, what happened these past few months?
Preparation for winter started earlier than ever before. Trusts were very much expecting and planning for the usual spike in activity over the winter months. Trusts were working with partners in primary care and social care, looking at different ways to maximise hospital capacity and improve patient flow (NHS Providers, 2017).
As local systems reviewed plans over the autumn, it was clear that bed capacity was going to be under substantial strain. Reports, followed by parliamentary debates, looked at the availability of hospital beds over winter and highlighted how the number in England had halved over the past 30 years. The reductions in acute beds have far outweighed the impact of national policies aimed at shifting care into the community and advancements in medical treatment could have provided, suggesting that the reductions were also due to limited resources (The King’s Fund, 2017).
Despite managing to immunise more staff, patients and vulnerable people than ever before, it was clear that flu was going to place additional strain on the NHS.
Warnings were building of a particularly bad strain of flu from the southern hemisphere. Despite managing to immunise more staff, patients and vulnerable people than ever before, it was clear that flu was going to place additional strain on the NHS.
An additional £335m cash injection was announced in the Autumn Budget, in November, to help the NHS manage through the winter. In many places, the money was not able to be used effectively, as trusts had been preparing for months without the knowledge that additional funding would be available. We had previously warned that July/August was the last point funding could be injected for the NHS to make best use of (NHS Providers, 2017).
One of the key elements of the preparation nationally was the alignment of NHS England and NHS Improvement in the creation of a single national director post for winter planning. A new feature of the national operating model this year was the creation of a new national emergency pressures panel (NEPP), chaired by Professor Sir Bruce Keogh. The panel was intended to provide independent clinical advice on system risk and, where required, to issue an appropriate regional and national response.
One of the key elements of the preparation nationally was the alignment of NHS England and NHS Improvement in the creation of a single national director post for winter planning.
The beginning of winter
As December started, with it came sub-zero temperatures. The erratic bad weather was another feature of this winter with temperatures falling to a low of -11.7 degrees on 28 February 2018 and more snow arriving through into March (Met Office, 2018).
Demand for services increased significantly through December. Many trusts reported that people who were going to hospitals and requesting ambulances were sicker and had more complex needs than ever; showing that this wasn’t just a case of lots of people using A&E services inappropriately.
The bad weather was followed by high levels of severe flu, the worst the NHS had seen in over seven years (NHS England, 2018) with many more people being admitted to hospital, and many in a critical condition.
The ambulance service had a particularly challenging time as it attempted to cope with high levels of demand from patients requiring hospital care. The demand was so high this winter that this equated to an ambulance arriving at all trusts with major emergency departments every 15minutes, 24 hours a day, all winter.
Over the first few weeks of the new year things worsened. The number of people being hospitalised as a result of flu increased, yet some capacity had to be taken out of the system with hospitals having to close on average 813 beds each week due to norovirus or diarrhoea and vomiting outbreaks. In the first week of January the NHS had an additional 4,700 escalation (temporary) beds open to cope with the influx; the highest number of temporary beds open over both this and last winter.
As the situation deteriorated the national bodies sought assurances from local systems about how they were responding. For many trusts, the more joined up approach by national system leaders did not translate to more alignment at the regional level. Trusts were still having to assure multiple regional and local teams on an hourly, daily and weekly basis with limited support.
News reports highlighted that in some places the quality of care was falling below the levels patients should expect, including the standards set out in the NHS constitution. Reports also highlighted the dedication and tireless effort NHS staff made over the period. Many staff stayed in hospitals over night or walked miles in the snow to get to work, just so they could ensure that their patients continued to receive the treatment and care they needed.
We have been extensively planning in advance of winter to ensure we can continue to deliver safe care; including significantly reducing our elective programme, and rescheduling outpatient clinics to free up medical and nursing staff to support the increased demand for emergency services.chief operating officer, Royal Free London NHS Foundation Trust
Due to the unprecedented demand the NHS was facing, the NEPP advised trusts to cancel non-urgent elective operations and relaxed the guidance for mixed sex accommodation breaches. This was interpreted in different ways by different parts of the country – some trusts were able to interpret this as guidance, others were told to treat it as an instruction.
This led to confusion for staff and patients. For those most pressurised systems, it provided national air cover for the difficult decisions they were having to take locally to defer non-urgent care. But for other trusts wishing to pursue their elective programme of work over the winter period, it was unhelpful blanket guidance which undermined local planning efforts.
In February, Simon Stevens warned that the NHS had endured its most pressurised month in NHS history, but we now know this continued with no sign of let up even after Easter.
The end of 2017/18
Winter pressures can also lead to financial pressures, as was the case over this year. The end of year deficit position for the provider sector is likely to come in around £1bn, including the additional winter funding from the budget. The financial position was particularly pressurised over the winter period due to lost elective income and increased costs, as trusts had to prioritise and free up capacity to cope with emergency demand.
But we also know that the challenges described here are not just difficulties facing acute settings. Problems with demand, funding and workforce are replicated across the whole heath and care system, encompassing mental health, primary and community care and social care.
The end of year deficit position for the provider sector is likely to come in around £1bn, including the additional winter funding from the budget.
Because of the plurality of problems we have repeatedly stated throughout winter that the NHS has reached a watershed moment.
The operational and delivery pressures were plain for everyone to see, with the issue piercing the public and politicians psyche. This winter appears to have been the tipping point with the Prime Minister now promising a "multi-year" funding plan for the NHS in England; an acknowledgement from the government that the NHS could not continue to struggle on without additional resources.
In the following sections we examine the impact of winter pressures, delving into three main areas; the ambulance service, A&E and capacity. What emerges is evidence of the widespread surge in demand, as well as systemic problems with capacity.