Is it time to change the Christmas story about winter pressures?

When the snowman brings the snow, sadly not everyone has a great big smile on their face, including many who work in the NHS.

With winter comes increasing pressure on staff, both in terms of providing services but also increased public scrutiny – the latter of which is perhaps most keenly felt in accident and emergency (A&E) departments. But is this a case of everyone focusing on Rudolph when actually there are eight other reindeer working just as hard to pull the sleigh?

Are we right to have such a strong focus on A&E performance?

To answer that question the best place to start is, ironically, A&E. Last winter there was extensive reporting in the media of four hour emergency care target breaches across the whole country. This target states that 95% of patients should be admitted, transferred or discharged within four hours of arriving at an A&E department.

Whilst it is worrying that the breaches were so widespread, approximately 92% of patients across England were still seen within the four hours. There were also breaches of other performance targets across the whole urgent care system (including A&E departments, ambulance trusts, NHS 111 and minor injuries units), which reflected the pressure the service was under.

In fact, the English system has still not fully recovered from last winter; the four hour target was breached in the first two quarters of 2015/16 (April to September) and it feels almost inevitable that widespread breaches will continue during this winter too.

One reason for the concentrated focus on A&E care may be the availability of data on performance. Last year the weekly updates made headline news but this year NHS England has decided to change their reporting of performance to a larger, monthly release. Weekly situation reports have been streamlined to raw numbers of attendances, admissions and bed closures.

Whilst this has been a controversial decision, it may not even provide any respite to the service from the media scrutiny as stories are already being written about a winter crisis in the NHS. These are likely to continue and intensify throughout the coming months.

Myths vs reality

To understand the real pressure winter brings to the NHS, we need to know why the targets are missed and also consider what the information available doesn’t show us about other aspects of quality.

There are many assumptions surrounding the effects of winter on the health system including that targets are missed because there are more people arriving at A&E during these months.

Although there were more people last year compared to the same time the year before, there are actually still fewer patients using A&E services during winter months than the rest of the year.

Despite this the number of emergency admissions does increase, suggesting that the patients who do arrive are sicker and therefore more likely to need more medical attention in A&E and a hospital bed.

Keeping the system moving

Because of the need to admit more patients, performance in other wards has as much effect on the four hour target as the A&E department itself. Monitor’s analysis of last year’s performance found that flow through the entire hospital was one of the most important factors contributing to the reported breaches of targets.

Patients can’t be admitted into a hospital with no beds available, and no beds can become available until inpatients are discharged. If there are delays in the transfers of care or the hospital is running at a very high capacity, a bottleneck forms at the exit of the hospital which is felt predominantly by staff trying desperately to treat all those at the entrance. This has other knock-on effects including patients not being admitted to the most appropriate wards and elective surgeries being cancelled.

Last year, delayed transfers of care increased, meaning that more patients who were well enough to be discharged remained in hospital beds. Whilst the data can be unreliable, this is at least partially due to reduced capacity in social and community care services. These services are becoming increasingly strained due to their very limited budgets and have their own pressures during the winter months.

The lack of capacity in areas such as social care may be one of the most important factors during this coming winter but there are not enough data to measure its impact. Is this why the media choses to keep its focus squarely on A&E performance?

The bigger picture

So what should be receiving more attention? It is obvious that this is a much broader picture than just A&E or even hospital care: community, primary care, public health and social care services all come under increased pressure during winter and can all have significant impacts on both the health care system and people’s health.

Recent figures revealed that there were 43,900 excess deaths last winter, 27% more than during non-winter months and the highest for 15 years. This was despite fairly mild weather. The majority of these deaths were people aged over 75 years old and around a third were due to respiratory diseases, such as flu and pneumonia.

It is likely that the reduced effectiveness of the flu vaccine last year, coupled with the fact that the most common strain was particularly virulent in older people contributed to the increase in deaths. But to what extent could this figure be reduced with improvements to public health or primary care?

Moreover, what other problems are the data not capturing? How many people are still risking their health living in a house that is too cold, or becoming socially isolated due to an inability or fear of navigating the harsher weather? All of these questions are just as important as the performance of A&E and have a direct effect on it, but don’t get the same attention – perhaps it is time to change the story?

Hannah Butcher is a Policy Intern at the Health Foundation