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NHS pressures – projections

Winter pressures graph 1 A&E four-hour wait – winter projections
  • Across the health service in England, trusts and GP practices are almost certain to endure the most pressurised winter on record.
  • Pressures in the NHS were worse over the summer than even the BMA’s worst-case projections, meaning services have experienced no respite.
  • Lack of recovery from summer, combined with other factors means the NHS in England is facing a 'perfect storm' this winter.
  • Like the summer, the winter could be substantially worse than our worst-case projections.
  • The Government must act now to prevent an unprecedented NHS crisis.


What would the coming winter look like?


  Four-hour wait (all A&Es) Four-hour wait (major A&Es) Trolley waits
Best-case scenario 85.2% 77.4% 205,378
Worst-case scenario 83.2% 74.4% 297,271
Last winter 85.1% 77.1% 213,877


For the purposes of simplification, winter refers to the months of January, February and March.

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 winter of 2019/20 could look like.

The NHS in England looks extremely likely to experience another winter of long waits for patients in A&Es, on trolleys in corridors and for treatment to begin. Almost all trusts will endure a protracted period of extremely high bed occupancy (reaching 100% in many cases) which will have serious implications throughout the system. 


Why will this winter be so bad?

Winter is always a difficult time for the NHS in England – cold weather inevitably brings an increase in demand, both in primary and secondary care. Flu season typically varies in severity, but small outbreaks can cause problems for local health systems.

Even when spikes in demand are anticipated and planned for, the level of available resourcing and staffing are often insufficient. 

Winter is also likely to be complicated by the addition of several other factors. There is strong evidence emerging that doctors feel that they are unable to pick up additional shifts for fear of dramatically increasing their tax bill, while planning for Brexit is likely to divert trusts’ focus at a time when they need to be entirely focused on winter. 

Any combination of these issues will almost certainly overwhelm the NHS this winter to an unprecedented extent, and decisive action must be taken as soon as possible to avert a major crisis. 


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 (eg 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 2019 and 2020.

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.


Download our full predictions


Read our feature: On the cusp of collapse: Peter Blackburn talks to doctors across the UK struggling on the front line.

  • Summer 2019


      Four-hour wait (all A&Es)
    Four-hour wait (all A&Es) Trolley waits
    Best-case scenario  88.5%  81.5% 139,900
    Worst-case scenario 86.5% 78.8% 167,300
    Actual  86.1% 78.1% 179,000


    What did the summer look like?

    We anticipated that the 2019 summer would be difficult for the NHS, although a promising recovery in March hinted that at worst any decline might be smaller than expected, while at best we might even see a small improvement. The reality proved much starker however, with performance figures recorded that were worse than even our worst-case scenario. 

    The summer of 2019 was comfortably the worst on record, worse even than the winter of 2016/17 (based on several key indicators). 

  • Winter 2018/19


      Best-case scenario   Worst-case scenario  Actual
     Four-hour wait (all A&Es)  84.3%  82.5%  85.1%
    Trolley waits of four or more hours  238,000  311,000  213,877


    What did the winter look like?

    An extremely mild winter led to a better than expected performance at trusts in 2018/19. Several records were still set however, including consecutive worth months establishing a new low in January and February for the four-hour wait at all A&Es and major A&Es, while the 83,554 trolley waits in January remains the highest figure ever recorded. 

    A comparatively warm March meant that performance improved more quickly than expected, although the recovery was not sustained, which almost certainly contributed to the extremely difficult summer that the NHS subsequently endured.

  • Summer 2018


      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.