Trust leaders tell us nationally led winter planning has been less visible compared to previous years. But they, along with their local A&E delivery boards, have been busy planning since May/June. Acute and ambulance trusts are aware that pressures in urgent and emergency care have implications for primary care, mental health services, community services and social care. All services will struggle this winter because of limited capacity in the system.

Planning broadly falls into six areas:

  • Patient flow. As in previous years, trusts and local delivery boards are focusing on optimising patient flow. This will involve tackling super stranded patients (with some trusts creating special taskforces), supporting effective discharge more broadly across inpatients, increasing hospital social work provision, and developing the use of specialty surge beds. Some trusts are also looking at the wholesale redesign of their emergency departments to create additional physical capacity.
  • Community and out of hospital provision. Acute and community trusts are working together along with others to increase system capacity. Some systems have funded new in-reach community nursing teams, while others have developed partnerships with voluntary organisations to create admissions avoidance schemes. At each end of the patient pathway, community teams are assisting patient flow. For example, some have created dedicated teams of Allied Health Professionals to manage out of out hospital referrals and assist with patient rehabilitation within their homes
  • Mental health. Busy emergency departments are not a suitable care setting for people in crisis. Acute trusts, mental health providers, ambulance services and the police are working together to better respond to individuals who need emergency support from a mental health crisis team. Initiatives include multi-disciplinary response teams and specialist mental health nurses in A&E departments. Mental health providers are expecting further A&E presentations, which will add more pressure on mental health inpatient beds and risk leading to increased out of area placements.
  • Primary care. In addition to the continuation of GP streaming in emergency departments, some trusts will also be placing GPs in critical parts of the system to observe and advise on changes to flow.
  • Patient transport. Systems are investing in patient transport to improve step down facilities, while others are looking to provide private ambulances to increase their ability to discharge patients. In one system, the acute and ambulance trusts are working together to increase the number of ambulance handover bays outside the emergency department.
  • Workforce. Lots of acute trusts are investing in additional workforce capacity, particular in their emergency departments, as well as evening staff and frailty teams. Many are also planning to provide additional management support.


Despite these preparations, many trusts remain concerned about the impact of winter. All systems continue to worry about the provision of social care with local authorities unable to cope, as they face huge financial challenges and increasing demand. This will have a major impact on patient flow during winter.