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NHS pressures – predictions

Winter pressures – beds

The summer of 2018 saw NHS pressures reach unprecedented levels, with A&E attendances, waiting times and admissions continuing to rise at a dramatic rate. In many cases, the performance seen at trusts in England was worse than that recorded in some previous winters. Using the same projection methods, we have now looked forward to the summer of 2019, which we will believe will be the worst on record.

What would the coming summer look like?


  Total attendances Percentage of patients seen, admitted or discharged within four hours or less (all A&Es) Percentage of patients seen, admitted or discharged within four hours or less (major A&Es) Trolley waits of four or more hours 
Scenario one 6,453,419  86.5% 78.8%  167,289 
Scenario two 6,363,985  88.5% 81.5%  139,876 
Summer 2018 6,183,253  89.3% 83.5%  127,617
Winter 2017 5,646,725 87.6% 81.3%  177,012


For the purposes of simplification, summer refers to the months of July, August and September.

These predictions above assume 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. 

The two scenarios above represent different versions of what the 2019 summer could look like. With a period of overwhelming pressure now a yearly occurrence during winter, trusts’ capacity to recover and restore performance levels during the summer has been severely diminished.

The NHS looks likely to experience another summer of long waits for patients in A&Es, on trolleys in corridors and for treatment to begin, while in extreme cases we could continue to see more cancellations of scheduled appointments and the prolonged use of escalation beds (traditionally reserved for periods of exceptionally high pressure). Please see our latest briefing on the issue of the continuing use of escalation beds beyond the winter months.

Why are the summer months now such a difficult period for the NHS?

Traditionally, the warmer summer months represented a cooling-off period after the hectic demands of winter. Though A&Es see more patients, those presenting are typically less likely to be admitted. Moreover, without the additional burden that cold weather also places on social care, it becomes easier to discharge patients, freeing up more beds.

In recent years, however, the demands placed on trusts in winter have been so severe that the effects continue to be felt well into spring and even summer. Consequently, beds remain full, waiting lists remain long and patients remain in A&E for hours on end.

Another implication of a pressurised summer is inevitably that the NHS’s ability to prepare for winter is also compromised; this, in turn, is likely to mean that winter pressures will extend well into next year (leading to a problematic summer).

How did we create our predictions?

In order to create a plausible range for the rest of the year’s data, we created rates of growth using different time frames to project forward.

The different rates of growth are based on the rate of change between the same calendar month of consecutive years (e.g. January 2017 and January 2018. We then determined what A&E performance would look like if that rate of change occurred during the same months of 2018 and 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.


  • Summer 2018 predictions

    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.

      Best-case scenario  Worst-case scenario Actual figures
    Attendances 5,887,000 6,214,000 6,176,000
    People waiting over four hours at A&E 613,000 774,000  660,000 
    Percentage of patients seen, admitted or discharged within four hours 89.6%   87.5%  89.3%   
    Emergency admissions 1,513,000   1,571,000  1,559,000 
    Trolley waits of four or more hours 127,000  147,000  125,000 
    Comparable winter 2015  2016  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 equalled 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.