• Current performance data shows that the NHS is in a more challenging position going into winter than it was at the same time last year. A&E performance in the first part of the year has dropped significantly compared to last year, as the rise in demand exceeds the capacity available. The pattern of each of the last five years suggests this will continue throughout winter.


  • Much of the resource and energy over the winter period goes into meeting demand for emergency care but acute hospital providers are now facing severe pressures across cancer and routine planned operations. Hospital trusts no longer have the ability, as they did in the past, to successfully juggle activity in these different areas, using over-performance in some areas in the summer months to prioritise emergency care in the winter months.


  • All the performance data from the first half of this year shows that the accelerating demand/capacity gap is a system-wide phenomenon, stretching services in primary and social care and community, ambulance and mental health services as well as hospital trusts. Despite welcome initiatives to co-ordinate and support system working, the steep and relentless rise in demand has meant that the gap between what all health and care services are being asked to deliver and what they are able to provide continues to grow.


  • Trusts report that social care provision is more fragile than last year. Whilst the £240m funding for social care announced by the health and social care secretary in October was welcome, local authorities needed to spend an extra £448m this year just to keep up with demand. In fact, they are scheduled to reduce adult social care spending by £700m according to the annual adult social care budget survey, and the impact of this is now being felt on the ground. Trusts report that they believe primary care has similarly become more fragile than last year and the number of GPs is not rising fast enough to meet its rapidly increasing workload.


  • Trusts are also facing rising workforce shortages, with NHS Improvement reporting a steep increase in vacancies at the end of Q1 and a 9% vacancy rate across the trust frontline, which is expected to increase throughout the rest of the year. This has a double negative effect. Acute, community, mental health and ambulance services are less able to temporarily expand services over winter to the same extent as they did last year. Existing staff have to carry a greater burden, making it more difficult to match last year’s level of extra discretionary staff effort. The recent heatwave, for example, has meant that staff have had to work much harder over the summer period and trusts report that they are finding it difficult to fill the same level of extra shifts compared to 12 months ago. Trusts also report that they are placing particular emphasis this year on supporting hard working staff even more effectively than last year.


  • The NHS remains under significant financial pressure. It is operating through the deepest and longest financial squeeze in NHS history, with the additional funding announced by the prime minister only due to start flowing from April 2019. Last year trusts were allocated an extra £337m winter funding in the Budget. Trusts have been told there will be no similar allocation this year as this money was incorporated into the main NHS budget at the beginning of the year. Trusts consistently report that commissioners, under increasing financial pressure, have absorbed this money into general budgets rather than allocating it to winter activity. In some places this means that valuable activities that were funded last year – such intermediate care beds - will not be funded this year.


  • Trusts will do their utmost to deliver high quality care this winter and preparations are well underway. The £145m extra capital funding allocated earlier this year will help a number of trusts increase capacity, improve patient flow, make changes to patient pathways and work more collaboratively across systems to manage demand differently.


  • Trusts are also working hard to reduce delayed transfers of care (DTOCs) and length of stay and there will be some benefit from these activities. However, it is notable that the significant reduction in delayed transfers of care achieved over the last year has now plateaued, some way short of the original target that was set. Trusts believe that the current national focus on reducing length of stay, particularly ’super stranded’ patients, will follow a similar trajectory. Progress will be made but the NHS will not hit the set target or the level of extra capacity needed to cope with expected extra demand.


  • The NHS will benefit from a second year of better, enhanced, national level winter planning. It will also benefit from a further year’s work of improving urgent care services and moving to new ways of providing care in a larger number of areas. It is possible that there will be lower volumes of flu related illness, as the NHS vaccinates more staff.


However, as the summary table below shows, NHS Providers concludes that, looking at the balance of potential benefits and risks compared to last year, there is a strong likelihood that this coming winter will be worse than last winter:


Factors that indicate potentially better performance and patient care compared to last winter

Factors that indicate potentially worse performance and patient care compared to last winter

Second year of better national level planning

Increased level and complexity of demand, currently significantly outstripping planning estimates

Further impact of general improvement initiatives and new care models

Worse A&E performance so far this year compared to last

Impact of £145m extra capital funding

Pressure across all other hospital activity restricting ability to prioritise urgent care

Impact of £240m extra social care funding

Greater pressure across mental health, community and ambulance services

Benefits of extra focus on reducing delayed transfers of care and length of stay

More fragile social care and less total real terms investment, even accounting for extra £240m

Potential for a less virulent and prevalent flu strain

More fragile primary care


Continuing financial pressure with 2018/19 NHS frontline budget increases less than the increase in cost and demand


Loss of last year’s dedicated £337m winter funding, now subsumed into general commissioning budgets


Higher level of staff vacancies


More tired and pressured workforce making it more difficult than last year to secure extra shifts


What is needed to break this cycle

The NHS is currently trapped in a perpetual series of winter crises that have become particularly intense over the last three to four years. Trusts believe that the new NHS long-term plan provides an important opportunity to start to break this cycle. To do so, the NHS frontline needs:

  • a clear understanding and acknowledgement of the scale of the extra and more complex demand that health and care services face and better mid to long term planning to meet this demand
  • sufficient capacity across the entire range of health and care services to match growing demand, rather than trying to run the NHS and social care “permanently in the red zone”
  • a realistic trajectory to recover NHS constitutional performance standards and the resource and time needed to deliver this
  • an immediate solution to current workforce challenges, and, over the longer term, a sustainable workforce plan.
  • more investment and greater pace and consistency in moving to joining up local health and care services and new ways of providing care, particularly for frail elderly patients to keep them in their own homes or local community, rather than in their local acute hospital when they do not need to be there.