The NHS in England came under unprecedented pressure during the 2017/18 winter, with A&E attendances, waiting times and admissions rising to alarming levels. With levels of pressure likely to exceed those from last year, the BMA has forecasted a range of possibilities for the levels of demand that the NHS is likely to experience during the 2018/19 winter.
What would the coming winter look like?
||Projection method 1
||Projection method 2
|Attendances at major A&Es
|People waiting over four hours at major A&Es
|Percentage of patients seen, admitted or discharged within four hours at all A&Es
|Total emergency admissions
|Trolley waits of four or more hours
For the purposes of simplification, winter refers to the months of January, February and March.
These predictions above are based on the assumption that recent or historic trends will continue, and do not take into account any ongoing or future interventions to reduce or better manage pressures and demands.
There is evidence that NHS leaders are trying very hard to ensure that trusts do not experience a winter similar to or even worse than last year’s, but at this stage it seems extremely hard to envision how that can be avoided.
The figures above paint a stark picture of what the 2018/19 winter could look like. The ability of trusts to manage pressures during the coldest months of the year has diminished year-on-year for some time now, so the likelihood is that the winter of 2018/19 will be even worse than the previous one.
The NHS looks set to see long waits for patients in ambulances, at A&Es, on trolleys in corridors and for treatment to begin, while cancellations of scheduled operations are also likely to be widespread.
Consequently, staff and patients will inevitably suffer as trusts experience almost unmanageable levels of pressure.
How prepared is the NHS to handle these additional pressures?
Whilst additional NHS funding could conceivably be used to mitigate pressures, it won’t be available until next year. Additionally, although the supplementary funding for social care will likely help with certain issues (e.g. long-stay occupancy of beds by patients awaiting care packages), it is unlikely to dramatically alter the overall picture for the coming winter.
Even if more funding and trust-level pressures planning mean that the winter most closely resembles the BMA’s ‘best-case’ scenario, this would still represent a profoundly problematic period in which primary and secondary care will once again be stretched to near-breaking point, surpassing records in terms of how much pressure the NHS endures.
In an October survey, the BMA discovered that less than one quarter of doctors (24.5%) feel that their place of work is prepared to deal with the coming winter, with 43.3% saying they feel their trust or surgery was either moderately or highly underprepared (out of a sample of 589 doctors).
More dramatic solutions are urgently needed to ensure that the NHS is sufficiently capable of enduring tough winters, including (but not limited to) better resourcing across the health service.
How did we create our predictions?
In order to create a plausible range for the rest of the year’s data, we used different methods to project forward, calculating two different rates of growth for key indicators over the coming winter:
1. The first rate of growth was based on the rate of change between the same calendar month of 2017 and 2018 (e.g. the difference between consecutive Januaries). We then determined what A&E performance would look like if that rate of change occurred during the same months of 2018 and 2019.
2. The second method involved calculating the rate of change between calendar months in the same year (e.g. January to February 2018) and then modelling what would happen if the same rate of change occurred between the same months of the following year (e.g. January to February 2019).
All data used in the projections is published by NHS England.
At present, there is a lack of data relating to primary care, so similar projections cannot be attempted at this time.
What pressures did we think the NHS would be under during the summer of 2018?
Based on recent and historic trends, our assessment during early 2018 was that rather than experiencing the customary fall in pressures during the summer, the NHS would experience similar levels of demand and activity during the summer as it did in the winter of just two or three years ago. Our assessment of the issues was picked up by national media.
The table below shows the range of our projections, along with the actual figures from the 2018 summer.
|People waiting over four hours at A&E
|Percentage of patients seen, admitted or discharged within four hours
|Trolley waits of four or more hours
||An amalgamation of the winters of 2015 & 2016
What did the summer look like?
The summer of 2018 was, as expected, a busy one. Attendances and admissions equaled or outstripped even our worst-case projections, with the former increasing by 4.2% compared with the previous summer, and the latter increasing by 5.7%.
Despite a notable increase in demand, the NHS proved arguably more resilient than expected, with the 0.8% deterioration in the four-hour wait and an increase of 8,500 trolley waits closest to the ‘best-case’ scenario as projected by the BMA.
However, that best-case scenario still represented a problematic period for the NHS, one in which performance as measured by key indicators was broadly similar to winters of just 2 or 3 years ago.
With no summer respite, it’s increasingly difficult to see how the NHS can be expected to recover from intensely pressurised winters. Though A&Es are often extremely busy during the summer months, generally patient flow is smoother as unplanned admissions fall and it becomes easier to discharge patients from beds, but now staff and patients face the same kind of difficulties (bed shortages, long waits) that are more traditionally associated with much colder months.