Winter pressures: the tip of the iceberg

It's difficult to think of winter pressures without immediately turning to the A&E and ambulance performance statistics. But, winter is about so much more than that.

Blog post

Published: 11/02/2016

Winter is often the most difficult time of year for acute NHS services. Fewer people arrive in A&E but more of those who do are unwell enough to need an emergency admission to hospital. The waiting list for elective treatment is increasing, but operations have to be postponed to make space on the wards. Delays in providing assessments and agreeing care packages mean people who are ready to be discharged can't be. The plumbing on which the health service depends gets clogged up, and poor flow can cause problems that impact on patient care. Based on performance in previous years, the winter of 2015–16 doesn’t look set to give the NHS an easy ride.

Today's new analysis from the QualityWatch research programme looks at the impact of winter pressures on the NHS. I find it difficult to think of winter pressures without immediately turning to the A&E and ambulance performance statistics. My excuse is that, in a former life as an NHS performance manager in the Department of Health, this was my bread and butter. Handling the daily situation reports on the number of times hospitals are diverting patients to other A&Es, 12-hour trolley waits and wards closed due to D&V (if you have to ask you probably don't want to know) made it hard to think of anything else.

Winter is about so much more than that, of course. Ambulances and A&E departments may be feeling the heat, but what about the wider ecosystem of GP surgeries, mental health and community services – let alone social care departments that are trying to cope with real-terms cuts to local government funding? National data is frustratingly limited in these areas, so it is much harder to assess.

Some of the people who come into contact with A&E or the ambulance service over the next few weeks will be utterly straightforward emergencies: my three-year-old had the misfortune to be one of these just the other week. Others will be horrendously complicated, where a wide range of NHS and other public services are involved but the national data only show the impact on emergency care.

That's not always a situation reflected in the wider dialogue about winter, which tends to major on A&E. Monitor's helpful analysis of what caused poor A&E performance in 2014­–15 found emergency departments had generally coped well and instead pointed the finger at high levels of hospital bed occupancy.

Even that is just the tip of the iceberg, frankly. The supply of, and demand for, primary, community and social care services is increasingly getting drawn into the debate about winter pressures. This is welcome, though we still have far from a complete picture of what happens in those wider settings. Furthermore, as the QualityWatch analysis highlights, there are some bigger drivers of pressures on the NHS. Can people afford to adequately heat their home during the winter months, for example?

Recent research by the University of York also highlighted that social inequalities also appear to have an impact on the pressure on A&E departments in England. This found people in the most deprived fifth of areas are nearly two-and-a-half times as likely as the least deprived fifth to end up in A&E for a preventable emergency, even after adjusting for age and gender differences.

This raises some big policy questions about inequalities and how public services and public policy more widely can contribute to improving health. The problem with icebergs is that they're mostly submerged. So are winter pressures, and developing greater resilience to cope with them requires better data across care sectors to ensure our services can actually work as a system to navigate them.