Did the NHS experience record pressures this winter?

The health service in England has endured a punishing winter. Stark warnings about a potential ‘quad-demic’, the ‘busiest year on record’ for A&E and ambulance services, and ’jampacked’ hospitals prompted comparisons with the COVID-19 pandemic. 

But how bad was winter 2024/25? Did the NHS report poorer performance and more operational problems than in recent years? Was this due to exceptionally severe conditions in terms of seasonal viruses and the demands on emergency care? And what can be learned as the health service begins to look ahead to next winter? 

Here, we present analysis of routinely collected and publicly available data on health service performance and the possible contributing factors. Our analysis covers three areas: an assessment of how urgent and emergency care performance for winter 2024/25 compares with previous winters; an examination of data on winter pressures; and some of the wider factors that might contribute to problems in urgent and emergency care. Further detail on the data used, our approach and its limitations are set out in Box 1.

Winter often brings heightened pressures for the health service. Lower temperatures increase the risk of new acute illnesses, including heart attack and stroke, and may exacerbate long-term conditions like asthma and diabetes. Viruses such as influenza, respiratory syncytial virus (RSV), norovirus and COVID-19 circulate year round but spread more easily during winter, with more people requiring hospitalisation for treatment. Poor weather conditions may lead to more injuries from slips, falls and other accidents. These and other factors contribute to a greater number of deaths occurring in winter months. 

Winter also creates additional challenges for delivering health services. Health care staff are tasked with providing seasonal vaccinations for influenza, RSV and COVID-19 to millions of people in addition to the usual demands of routine care. Infection control measures to prevent the rapid spread of vomiting bugs in hospital by keeping infected patients removed from others typically lead to some beds being left unused. Seasonal viruses and other illnesses contribute to higher sickness absence among health care workers. Adverse weather events may also disrupt staff travel to work and the movement of essential supplies or damage buildings used to provide services. 

While the NHS can anticipate and prepare for winter, some years are more difficult than others, and the extent to which each factor impacts health services varies from year to year. Higher illness levels and other health service challenges during winter can result in greater pressures in urgent and emergency care, with consequences for patient experience and outcomes, working conditions for NHS staff and public satisfaction. For example, longer waits before admission have been linked with excess deaths. Delays in A&E disproportionately affect some groups of patients, such as those experiencing a mental health crisis. Resorting to ‘corridor care’ contributes to poor morale among NHS staff and a poor experience for patients. Public dissatisfaction with A&E services has risen sharply from 37% in 2023 to 52% in 2024, and improving A&E waiting times is now the second highest priority for the public according to our recent polling. 

The urgent and emergency care recovery plan produced under the last government aimed to improve performance by increasing capacity, growing the workforce and improving discharge delays, but failed to hit its target of 76% of A&E patients waiting less than 4 hours by March 2024. The new government has tasked the NHS with reaching 78% by March 2026 and is developing a new recovery plan to bring about more ambitious improvements.   

The NHS constitutional standard is that at least 95% of patients attending A&E should be admitted, discharged or transferred within 4 hours of arrival. Over this past winter, 73% of all A&E patients were seen within 4 hours, slightly more than in the winters of 2022/23 (70%) and 2023/24 (71%) but far below the 95% constitutional standard. Performance was even worse at major emergency departments, with less than 60% of patients treated within 4 hours. While performance has steadily fallen since the NHS last met the 95% standard in 2014/15, performance in recent winters has been substantially worse than in winters before the pandemic (Figure 1). 

While winter is always a challenging period for the NHS, the performance of urgent and emergency care services over winter has been markedly worse in recent years compared with pre-COVID-19, with a catalogue of record or near-record high operational pressures. 

This section considers the extent to which changes in the levels of hospitalisations for common winter illnesses and demand for urgent and emergency care might explain the dip in operational performance seen in winter 2024/25. 

Patients in hospital with flu

This winter, a record number of hospital bed days were needed for patients with flu – over 315,000 compared with around 174,000 in 2023/24 and around 211,000 in 2022/23 (earlier data are not available). This is likely because the weekly admission rate peaked before Christmas at a level higher than most winters; the peak was lower than in 2022/23 but took longer to fall back to normal levels (Figure 5). Admission rates to critical care were similar to the past two winters and lower than in 2018/19, suggesting flu severity was not higher than usual (Figure 5). While pressures from flu were certainly difficult this winter, hospital admissions followed similar patterns to previous winters from late January.  

The previous section showed that the levels of patients in hospital with flu and diarrhoea and vomiting have been high but not unprecedented. However, the decline in emergency admissions signals the impact of these pressures in a system already overstretched and performing poorly. In this section, we explore some of the factors that might be impacting NHS operational performance during the winter months – although we do not consider the impact of longer term productivity challenges. 

High bed occupancy and delayed discharges

Bed occupancy has been increasing for some time, with consistently high levels in winter both pre-COVID-19 and in recent years (Figure 8). While the NHS had an average of around 2,000 more general and acute beds open this winter than in winter 2022/23, bed occupancy has remained high. Levels have been above the 85% threshold recommended by the Royal College of Emergency Medicine to deliver care safely, year round, since at least 2010. Bed occupancy first exceeded 90% in winter 2014/15 and the maximum threshold of 92% set by the NHS to maintain patient flow in winter 2017/18, with even higher occupancy among adult general and acute beds. The UK has very high levels of bed occupancy compared with most other European countries, including France and Germany. 

This winter has seen no shortage of harrowing accounts of patients being treated in uncomfortable, undignified and unsafe conditions and NHS staff working in near-impossible circumstances to deliver care. These experiences sit behind the statistics used in this analysis, which show a picture of a health system in distress – performing far worse than before the pandemic and reporting record or near-record levels of operational problems across urgent and emergency care. Only 73% of A&E patients were seen within 4 hours this winter, similar to the past two winters, and far below the 95% constitutional standard. The number of people experiencing 12-hour waits before admission reached a new record high of over 60,000 patients in January, and A&E diverts and ambulance handover delays were worse than in previous winters. Lack of progress has seen recovery goals for improving A&E waits and ambulance response times pushed back to next year. This all raises key questions for policymakers working on a new Urgent and Emergency Care Plan and the 10-year Health Plan.

Our analysis highlights several areas where severe pressures this winter could have contributed to these operational pressures: diarrhoea and vomiting, including norovirus, was at notably high levels, and the total bed days used for flu patients was significantly higher than in recent years. These higher levels of winter pressures occurred in a system with very high bed occupancy and discharge delays, and in the context of a renewed political focus on reducing waiting times for elective care. Together, these likely led hospitals to increase their admission thresholds for emergency conditions, contributing to a reduction in emergency admissions this winter compared with the past, while the number of elective admissions appears to have increased. In other ways, winter 2024/25 was not exceptional. Flu hospital admissions peaked at a similar level to in 2022/23, and critical care admissions were elevated for far less time than in 2017/18 and 2018/19. Admissions for RSV followed similar patterns to recent years, while COVID-19 admissions remained very low. Fewer patients attended major A&E departments in winter 2024/25 than in 2023/24. Overall, it is hard to conclude the conditions in winter 2024/25 were far above what the NHS can normally expect. 

The longer view provided by this analysis suggests the NHS experienced a disproportionate number of operational problems in winter 2024/25, even allowing for the challenging conditions. Attributing the scale of operational problems in 2024/25 to external factors such as winter illnesses and higher demand risks offering false comfort about the underlying resilience of the health service. This means policymakers need to focus on the underlying issues contributing to the escalating winter crises experienced since 2010 if the NHS is ever to recover the 4-hour standard for A&E and respond to future national health emergencies, or even more localised major incidents. These underlying issues include increasing hospital capacity, improving staff morale and improving capacity in social care and community services to help reduce discharge delays – which cost the NHS far more bed days this winter than it lost to seasonal viruses.

Making these changes will take focused effort over the long term. In the meantime, some short-term measures may help ease pressure on the NHS. Opening extra hospital beds may help, but hospitals face competing political pressure to reach emergency and elective care recovery targets. Hospitals must have the operational capability needed to manage capacity effectively and political backing to make slower progress on elective recovery when emergency pressures spike. There is also clear scope to improve flu vaccination uptake for at-risk people aged 65 years and younger, pregnant women and children. Similarly, uptake of flu and COVID-19 vaccines among front-line hospital workers is worryingly low, indicating potential vulnerability to future flu and COVID-19 epidemics. Uptake also varied considerably by NHS trust, which may highlight the need for winter vaccines to be made a national priority with targeted support to maximise coverage. 

At the hospital front door, winter preparations have often emphasised the need to divert lower acuity patients to urgent treatment centres or community-based alternatives to ease pressures on A&E. But the patients who face the longest delays at major A&E departments are likely the least able to be appropriately diverted because they often need diagnostic tests and treatment only available in hospital. Various interventions, such as same-day emergency care, virtual wards and urgent community response services have been developed with the aim of providing appropriate urgent treatment without patients needing to be admitted. A better understanding of what works and how these interventions can be implemented effectively is needed – as is the system leadership and operational management required to make this happen. 

Winter may be inevitable, but an annual NHS crisis does not have to be – even if that may be hard to imagine given its current state. ‘Winter pressures’ have been felt by the NHS year round, including since before the pandemic. The question is not how we better prepare for winter but rather how we improve baseline capacity and resilience within the NHS such that it can deal with both year-round and seasonal pressures without major impacts on urgent and emergency care performance. We hope the 10-Year Health Plan will pave the way for returning the NHS to a more stable state. 

We are grateful to Dr Sarah James and Dr Robert Price for sharing their thoughts on our research, and to Hollie Miller and Melissa Co for analysing data and producing charts for this analysis.