The NHS in England risks its traditionally poorer levels of performance in winter becoming the norm in summer, reveals an extensive analysis of the last five years of data by leading health charities the Nuffield Trust and the Health Foundation (see note 1). The report shows that problems that are usually observed only during the winter months are increasingly being seen at other times of year – which meant that the NHS entered winter 2015/16 from a historically poor starting point. The authors argue that this could lead to a ‘downward spiral’ in performance.
Winter pressures: what’s going on behind the scenes? also demonstrates that by many measures, last winter (2014/15) was the most difficult for the NHS since weekly figures began to be collected, despite weather conditions not being especially bad. This leads to fears that the current winter could be tougher still.
However, it also highlights the fact that in some areas – such as A&E closures, and the average length of time patients spend in A&E – the NHS has been coping well with winter pressures.
As part of the joint Nuffield Trust and Health Foundation QualityWatch programme (see note 2), the report authors set out to examine whether the relentless focus on the four hour A&E target for hospitals gives the full picture of winter pressures on NHS trusts. The study analyses performance across 29 different indicators over the past five years from 2010 to autumn 2015, to shine a light on the pressure hospital services experience in winter and increase understanding of what is a complex issue. The researchers compared annual trends over time to see absolute differences between winters, and also how demand and performance varied between winter and summer. They also looked at the weekly patterns to see whether there were any particular points during the winter months where the system might be under more strain.
Indicators that have traditionally shown poorer performance only in winter, but which the report shows are now declining in summer as well, include:
- Trolley waits: these are defined as patients having to wait between 4 and 12 hours after a decision has been made by an A&E doctor to admit them to the main hospital. The researchers show that although the number of patients waiting still peaks in winter, the number subject to trolley waits in summer is also increasing – making it harder every year to return to ‘normal’. So the number of trolley waits at the end of summer 2015 was higher not just than in any of the previous four summers studied, but also greater than in any of the four winters before 2014/15 (see note 3). In other words, the starting point for winter is continually worsening for this indicator.
- Similarly, the analysis demonstrates that ambulance response times, although they too traditionally suffer a dip in performance in winter, are now recording continually worsening performance every summer, too (see note 4).
Meanwhile, measures that showed their worst performance to date last winter included:
- The number of ambulances queuing outside A&E remained fairly steady year-on-year up to 2013/14 at around 60,000 for the winter months (week 45 – week 6 inclusive), but last winter considerably increased to 96,150 over the same period. These delays could then have a significant knock-on effect on ambulances’ ability to meet response time targets for Category A – the most urgent – calls (see note 5).
- The number of trolley waits has increased substantially since 2010, when the figure was almost 14,000, but last winter reached a peak of 45,000 in December 2014 – this number comprised 9% of all patients where there was a decision to admit them to hospital, and 2% of all A&E attendance.
- The number of patients waiting more than 12 hours after a decision was made to admit them to the hospital reached a peak of 270 in the first week of 2015, a very significant increase on the same week over the previous four years (in that week for both 2011 and 2012, the number was only 7; in 2013 it was 11 and in 2014 only 33). While there was a recovery in the second week, this rose again to around 115 in weeks 3–5. While the number is very small in the context of the total number of people going to A&E, it is clear that a growing number of patients are waiting an extremely long time.
The report also reveals other more general trends, some of which may run counter to the public’s view of the NHS in winter:
- Fewer people attend A&E in winter. By last year, 100,000 more people went to A&E in summer than in winter (1,249,000 attendances in June 2015 compared with 1,124,000 in January 2015) – laying to rest the idea that any ‘winter crisis’ in the NHS is caused by extra people going to A&E in the winter months. Overall fewer people attend in winter, with a defined clear ‘dip’ in numbers attending in December/January each year. However, contrary to the broader trend, the number of older people going to A&E peaks in December (see note 6). In addition, a greater number of people who attend in winter require emergency admission to hospital.
- People’s median (average) experience of waiting in A&E for treatment has changed little since 2011, and by October 2015 stood at 56 minutes.
- The number of hospital beds decreased by 8,000 over the five year period, a 7.5% reduction (see note 7). At the same time, there was a very large increase in the number of days patients were in hospital when they should have been transferred elsewhere – these went up from 109,918 delayed days in August 2010 to 160,094 in October 2015, an increase of 46%.
However, the report also shows that over the five years studied, the NHS has coped well with some pressures. For example:
- The average daily number of beds closed due to diarrhoea and vomiting/norovirus-like symptoms decreased from 1,133 in 2010/11 to 920 in 2014/15.
- The number of so-called ‘A&E diverts’ (an agreed temporary diversion of patients to other A&E departments in the area to provide temporary respite) has remained stable over the last five years at around 250 per winter.
The report also explores a number of common assumptions about the influence on NHS performance of the number of available beds and staff, of patients’ progress through the system, and of care given outside hospitals.
Commenting on the report’s findings, lead author Dr Elizabeth Fisher of the Nuffield Trust said:
“Every year, the winter months produce a combination of circumstances that understandably make it harder for the NHS to cope. Respiratory problems, strokes and heart attacks are all more likely to occur in cold weather, for example, while flu and norovirus are also more common then. We see the effect of these pressures every winter when the NHS shows dips in performance against some measures.
“But the new and worrying development we’ve identified in our analysis is that although those factors aren’t present in summer, the summer months have now started to show performance similar to that seen in past winters. This has a knock-on effect in the months that follow, particularly on planned operations, thus making it harder for the Health Service to cope each winter. It’s then more difficult for hospitals to recover the following summer, which could lead to a continued downward spiral.”
Tim Gardner, Senior Fellow at the Health Foundation, said:
“Infection rates, bed capacity, the health of older people and how they are supported in the community and the rising demand all contribute to the pressure the NHS experiences during winter. All these factors need to be understood better, in particular the impact of threadbare social care.”
For more information, please contact Katherine Jarman or Mark Dayan in the Nuffield Trust press office, on 020 7462 0555/0538.
NOTES TO EDITORS
- ‘Winter pressures on the NHS: What’s Going On Behind the Scenes?’, Nuffield Trust, Dr Elizabeth Fisher and Holly Dorning. The Nuffield Trust is an independent health charity. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK.
- The QualityWatch programme was established by the Nuffield Trust and the Health Foundation 2013. It is tracking over 300 key health and social care indicators over time.
- See figure 3.13 in the report.
- See figure 3.11 in the report.
- See figure 3.11 in the report.
- Those aged 60-79, and 80+ - see figure 3.2 in the report.
- See figure 3.4 in the report.