Introduction
Today the weekly winter situation reports by NHS England were published, alongside the monthly performance and activity statistics. These offer valuable insight into the situation on the ground as trusts brave an exceptionally hard winter for the NHS.
These data continue to show us how staff are working tirelessly under severe pressures to deliver an ambitious catch-up plan, while responding to ongoing COVID-19 and flu cases, and the usual seasonal illnesses.
This week's winter data (2 – 8 January) show how bed occupancy increased further and how capacity is being impacted by norovirus, diarrhoea and vomiting. Data continue to highlight ongoing issues with patient flow, as we see a record number of patients remaining in hospital despite being medically fit to leave.
Meanwhile, the monthly activity and performance statistics provide useful context to the state of the sector. Key points to highlight include:
Ambulance activity: A very busy December for ambulance services, with the highest number of category 1 incidents on record (over 101,000), almost a fifth higher than the previous record of about 86,000.
Emergency care activity: Demand remains high in A&E departments, with 2.3 million attendances registered in December, making it the highest figure on record. Equally, December saw over half a million emergency admissions.
Elective care: Activity increased and the total waiting list has decreased for the first time since the beginning of the pandemic. Progress was made on the numbers of those waiting more than 18, 52, 78 and 104 weeks as well.
Diagnostics: Activity increased in November, with almost 2.2 million diagnostic tests carried out, but the waiting list remains high at nearly 1.6 million.
Cancer: Activity for the two-week pathway is above levels seen one year ago (7% higher) and also above pre-pandemic levels (31% higher than November 2019).
Urgent community: As of November 2022, 81% of urgent community response referrals met the two-hour standard.
Winter situation report (2 – 8 January)
A&E diverts and A&E closures: there were no A&E closures again this week. There were a total of 23 A&E diverts this week, six more than the week prior.
Adult critical care: Bed occupancy rose this week to 83.4%, up from 81.5%. This is above levels seen in the same week last year (77.0%).
Ambulance arrivals: A total of 72,029 patients arrived by ambulance in the latest week. This is an increase of about 1% since last week and a decrease of 11% compared to the same week last year.
Ambulance handovers: 36% of ambulance handovers were delayed by 30 minutes or more, a decrease from 44% last week. 19% were delayed by 60 minutes or more. This is a decrease from 26% last week. A total of 36,369 hours were lost to ambulance handover delays.
Critical care: Adult critical care bed occupancy rose this week to 83.4%, up from 81.5%. This is above levels seen in the same week last year (77.0%).
Diarrhoea and vomiting (D&V): The number of beds closed due to D&V and norovirus has increased this week, with an average of 513 beds closed per day. This is up from 391 last week and also above levels seen this time last year (160).
Discharges: There were an average of 22,603 patients each day who no longer met the criteria to reside, an increase of about 11% (2,301 more). A slightly smaller proportion of patients remained in hospital this week, with 62.2% (or 14,069) staying in hospital, a slightly smaller figure compared to 63.1% the week prior.
Flu: This week the average number of general and acute (G&A) beds occupied by flu patients each day decreased by 4% to 4,914. An average of 349 critical care beds were occupied by flu patients each day this week (4% more than the week before). Compared to the same week last year, the average number of G&A beds occupied by flu patients each day has increased by 10,716% (4,868 more). The average number of critical care beds occupied by flu patients has increased by 12,742% from the same time last year (346 more). These figures are considerably higher compared to this week last year as flu was not as prevalent due to COVID-19 restrictions and social distancing.
G&A beds: There were an average of 102,134 G&A beds open each day – 6.2% higher than the same time last year (5,978 more). On average each day, 257 beds were unavailable and void to non-COVID infections. Average bed occupancy remains high at 94.6%. This is an increase of 3.2 percentage points compared to the same week last year.
Long stay: The number of patients staying in hospital longer than seven, 14 and 21 days has continued to increase this week (up by 6%, 10% and 7% respectively). Compared to the same time last year, the numbers of patients staying in hospital for longer than seven, 14 and 21 days have all increased (up by 15%, 17%, and 14% respectively).
Neonatal intensive care beds: Occupancy has slightly increased from last week and is at 66.3%, down from 65.5% last week and down from 69.7% the same week a year before. The average number of care beds open is at 1,689, 1% smaller than the week before and 0.5% higher than the same week last year.
Paediatric intensive care beds: Occupancy has slightly increased this week to 87.4%, up from 86.63% last week. This is higher than the same week last year (73.5%). The average number of care beds open has slightly decreased to 361, two fewer than last week and three fewer compared to the same week last year.
Staff absences: There was an average of 57,528 total absences each day this week, of which 11% were COVID-19 related (6,595). The total number of staff absences decreased from the week before, but the proportion of COVID-19 related absences has remained similar.
Our view
Trust leaders predicted the toughest winter ever for the NHS and these data suggest it may well be. Performance and activity data unequivocally show how busy trusts have been. A&E departments saw a particularly active December in which record numbers of attendances were observed, as well as over half a million admissions and nearly 55,000 patients waited more than 12 hours from the decision to admit to admission.
The ambulance sector had a remarkably busy month as well, with record numbers of category 1 incidents also registered, now over 100,000, and a deterioration of average response times, with category 2 calls average response time now at an hour and a half – severely missing the 18 minutes target.
The winter situation report data are also showing how in the first week of January, over one third of ambulance handovers were delayed by 30 minutes or more, a key sign of challenges with patient flow, also seen in the record number of medically fit patients remaining in hospital this week.
Bed capacity remains an issue, and we are seeing increases in bed occupancy for G&A beds, critical care beds, but also neonatal and paediatric intensive care beds.
That said, as the NHS continues its intense and ambitious catch up plan to clear backlogs, progress has been made and should be noted. Diagnostic activity increased in November, cancer activity is up, and the size of the elective care waiting list slightly decreased for the first time since the beginning of the pandemic. These gains have been made due to the hard work of NHS staff who, facing extremely difficult circumstances, endeavour to provide the best possible care to patients across the country.
Urgent and emergency care: Tackling a national emergency
Dr Prem Premachandran, emergency medicine consultant, Frimley Health NHS Foundation Trust and Care Quality Commission (CQC) national professional advisor for urgent emergency care (UEC) discusses the creation and purpose of PEOPLE FIRST, an online tool designed to encourage safe and best practice for those working in UEC.
I've been an emergency medicine consultant for 25 years. In that time, I have seen first-hand how the gradual rise in demand for care and the increase in acuity and complexity of healthcare needs has intensified pressure on services and the staff delivering them. The pandemic brought unprecedented challenges, yet the resilience and commitment of the health and care workforce remained unwavering. That continues to be the case as they battle the cumulative impact of flu, COVID-19, and Strep A.
I'm extremely proud of the colleagues that I work with. But right now, UEC services are being pushed harder than ever, resulting in patient care being compromised. We desperately want to provide a high standard of care for everyone, but increased demand and limitations in capacity is leading to unacceptably long waits for ambulances, for a bed on a hospital ward or to be discharged home once medically fit. Staffing levels are stretched, morale is low, and with repeated media reports of patients deteriorating or suffering harm, public concern is understandably growing.
We can't ignore the crisis in urgent and emergency care.
Emergency medicine consultant, Frimley Health NHS Foundation Trust and Care Quality Commission
We can't ignore the crisis in UEC. But even in the face of this overwhelming pressure, I believe we can take action to help mitigate risks and ensure a better level of care. Ultimately, there is a need for a new model of collaborative UEC, but in the short-term we can still drive integration and improvement. With compassionate, collaborative leadership, and creative pathways supported by technology and innovation I think we can make a difference.
As a national professional advisor for CQC, I provide guidance to inform the regulator's oversight of UEC services. I also lead the CQC's national emergency medicine specialist advisor forum. The forum brings together senior medical professionals from across the country, united by a passion and drive to improve patient safety. We work collaboratively with CQC and offer inspectors insight into the reality of delivering frontline UEC and the pressures being faced.
Set up in 2020, the forum has helped to develop a number of resources for people working in and leading services. The latest of those resources is the PEOPLE FIRST online tool for integrated care system (ICS) leaders and the services within those systems. It offers a whole system perspective and recognises the UEC pathway as a continuum, with solutions required across primary care, secondary care, community care and social care. It highlights good practice and examples of what is working well. PEOPLE FIRST doesn't have all the answers, but as a practical tool it can be used to guide safe care and to spur innovative practice.
At Frimley Health NHS Foundation Trust, we are starting to put the principles behind PEOPLE FIRST into action. It has helped us think differently about how we can deliver the best possible care to patients with the resources we have available.
The PEOPLE FIRST approach to optimising flow is borne out in the trust's urgent community response and frailty virtual ward team. The team is led by a consultant geriatrician and includes advanced nurse practitioners, registered nurses, therapists and pharmacists. Together they can quickly respond in person to elderly patients in their own home or care home who may have suffered a fall or be experiencing difficulties due to reduced mobility, as well as acutely unwell patients with infections or more serious conditions.
Our aim is to provide the same level of acute intervention they would receive if they were an inpatient on a medical ward, but without them having to come to the emergency department. Where patients require ongoing treatment, they are admitted to the frailty virtual ward and receive daily visits from nursing staff and therapists. Patients are discharged from the service with ongoing support from other community services and in cases where a higher level of care is required, they will be transferred to one of the trusts community rehabilitation hospitals or referred to the frailty same day emergency care team.
It's not just a tool to increase flow, but also to improve staff retention, support efforts to prevent ill health, link up local services and to design and deliver services based on people's needs.
Emergency medicine consultant, Frimley Health NHS Foundation Trust and Care Quality Commission
Not only is the approach helping to avoid unnecessary admissions, it also means we can discharge inpatients home earlier onto the frailty virtual ward for ongoing treatment. This improves flow through the hospital and reduces pressure on the emergency department. From April to October 2022, the team cared for 861 patients. Of these, 90% were responded to within two hours and hospital admission was avoided in 85% of cases. Everyone we saw said they would like treatment at home again in the future and would recommend the service to others.
This is just one example, and PEOPLE FIRST includes many more. It's not just a tool to increase flow, but also to improve staff retention, support efforts to prevent ill health, link up local services and to design and deliver services based on people's needs. We cannot deny the enormity of the challenges facing UEC services, or the importance of system wide service collaboration in their delivery. There are no quick fixes, but there are ways we can work differently that maximise the expertise and commitment of the workforce to drive forward innovation and improve the quality and safety of care.
The Provider Podcast – Winter Watch: How are trusts coping?
In this episode, Adam Brimelow, director of communications at NHS Providers, reflects on the toughest winter in the history of the NHS with insights from Miriam Deakin, director of policy and strategy. There's also a summary of what the performance figures (published 12 January 2023) tell us, from Luís Costa da Silva, senior research analyst.
In addition to this, we hear from Hospital at Home physician professor Dan Lasserson and consultant in acute medicine and geriatrics Dr Jordan Bowen of Oxford University Hospitals NHS Foundation Trust. They explain how their Hospital at Home programme has helped ease pressures while offering a more convenient and comfortable environment for patients. They also talk about working with the BBC Panorama team which has featured their approach in a new documentary.