The NHS this winter: looking beneath the national view

It’s that time of year again. Winter is nearly over and senior NHS leaders and policymakers will be reviewing the data to see how the NHS in England has performed this year, not least to understand whether the preparations put in place have paid off or not.

There is no shortage of data to analyse: NHS England publishes data on a range of winter-related indicators, which can be compared to previous years. The emerging conclusion from NHS England's Weekly Winter Situation Reports is that the NHS is doing very slightly better than last year at a national level, helped by milder temperatures. But what about at a local level?

Why is the local perspective important?

A place-based, local health system approach is central to The NHS Long Term Plan. The ability of Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to manage winter pressures at a local level will have a bearing on their capacity to improve health and social care for their populations.

However, it is much harder to get a picture of NHS performance at this local ‘health system’ level. Some performance data are publicly available at STP level and NHS England has published an STP progress dashboard, but it was last updated in July 2017 with 2016/17 data . 

A closer look

To shed some light on the local picture, my colleagues and I have created two data visualisations giving an overview of how the pressures vary across the country. (We don’t provide detailed analysis here of the many potential factors influencing this variation.)

We mapped some of the winter data across STPs in England, matching the acute hospital trusts to the 44 STPs, according to the most recent, comprehensive information from NHS England. (If you’d like to find out more, we’ve also written an accompanying blog about our methodology, including why we have excluded certain trusts.) 

Three indicators of trust performance

For our first visualization below, we wanted to explore the average trust performance within each STP, so we chose three key indicators to illustrate patient flow through hospitals: four hour A&E waits for major attendances, bed occupancy and ‘super stranded’ patient rates (patients whose stay in hospital exceeds 21 days). By using the filters at the top, you can contrast the results by winter, and/or by individual months.

What do the data tell us?

In early January, the national picture suggested some grounds for cautious optimism regarding performance up to that point. Generally, this seems to hold out at a local system-level with less pressure in many areas this December compared to last. 

• In 32 of the 44 STPs, average trust performance improved against the four hour A&E target for major A&Es in December 2018 relative to December 2017. 
• Unfortunately, performance seemed to deteriorate somewhat from mid-January, perhaps in part due to colder weather and a rise in flu levels. An initial look at the local view of bed occupancy rates and A&E waiting times also seems to reflect the national picture here, suggesting a big step up in pressure between December and January. 
• Meanwhile, there seems to be less variation through the winter months in the rate of super stranded patients – particularly in 2018/19.

However, national-level trends do not hold out everywhere. For example, reducing the number of super stranded patients has been a priority in NHS policy – and weekly statistics for England show signs of better joint working by the NHS and social care services on this front. Overall this winter, there has been a lower percentage of hospital beds occupied by super stranded patients. However, at a local level, a minority of STPs performed worse in this regard compared to last year, with 8 STPs experiencing a higher average proportion of super stranded patients. 

Another – perhaps surprising – feature of mapping the data by STP is the apparent absence of a clear connection between the different indicators. That is, a higher proportion of patients waiting over four hours in A&E does not necessarily correspond to higher bed occupancy in the same STP and vice-versa. Similarly, an STP that experienced a relatively bad winter last year didn’t necessarily experience comparable pressures this time around.

Zooming in on bed occupancy rates

We also thought it would be interesting to look more closely at variation in bed occupancy rates from week to week, and how this compared to last year. By clicking on different areas of the map, you can see that STP’s weekly variation in bed occupancy rate over winter in the chart below.

What do the data tell us?

Average daily bed occupancy rates show some variation across the country, but it is clear there is significant pressure everywhere. Last winter, NHS Improvement and NHS England recommended that occupancy should be below 92% to support patient flow through hospitals. 

• More than three quarters of STPs have trust averages above this 92% threshold (pink or red on the map), both this winter and last. 
• While there are fewer STPs where trusts average over 96% bed occupancy (red) than last winter, some have higher levels. 
• In every STP, bed occupancy averages above 85%, the threshold used by the Royal College of Emergency Medicine and the Royal College of Surgeons.
• Looking at the first and last weeks of winter, national bed occupancy levels decreased from 94.3% in week 49 (beginning 3 December 2018) to 94.0% in week 9 (beginning 25 February 2019) – compared to an increase from 94.8% to 95.4% between the same weeks last winter. However, this national trend was not reflected in some STPs, where on average trusts had a higher percentage of beds occupied in week 49 compared to week 6.

So, even though the national picture is important, it may mask that some parts of the country have faced even greater pressures than others this winter. It is also worth noting that even within STP areas, there is further variation between trusts. 

We have not attempted to analyse why some areas are experiencing higher pressures than others, or why some are performing better this year compared to last and vice-versa. Yet, if the future of the NHS lies within local health systems, these variations are certainly worthy of further scrutiny.

Lucinda Allen (@LucindaRAllen) is a Quality Intern at the Health Foundation

Please note: the national averages for bed occupancy levels discussed above will vary from the national aggregates reported in NHS England’s Winter Situation Reports due to being a different measure and having undergone data cleaning.