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BRIEFING PAPER

Number 8210, 3rd April 2018

NHS Winter Pressures 2017/18, England

By Carl Baker

Contents: 1. Introduction & Context 2. Emergency Care 3. Ambulances and NHS 111 4. Beds and capacity

2 NHS Winter Pressures 2017/18, England

Contents 1. Introduction & Context 2

Summary Graphic 3

2. Emergency Care 4 2.1 A&E attendances and waiting times 4 2.2 Emergency Admissions and Trolley Waits 5

Map of A&E performance in England 6 2.3 A&E Diverts 7

3. Ambulances and NHS 111 8 3.1 Ambulance handover delays 8 3.2 Ambulance response times 10 3.3 NHS 111 11

4. Beds and capacity 13 4.1 Bed availability and occupancy 13 4.2 Delayed discharges 18 4.3 Beds closed due to norovirus 19 4.4 Cancelled operations 21

1. Introduction & Context Over the winter period, NHS England publishes daily situation reports on winter pressures facing acute hospital trusts and NHS 111 providers. NHS England states that the winter dataset is subject to only minimal validation because it is turned around quickly, but that it is nevertheless fit for purpose. Unless otherwise specified, data in this publication is sourced from these winter situation reports.

This year, data on ambulance handover delays and the number of long stay patients was added to the publication. However, data on operational pressure escalation levels was removed from the publication. This system is still in use, but data on which trusts reported major pressures and/or problems delivering comprehensive care was not made public this winter.

This briefing gives an overview of NHS data on demand, supply and performance in England. Other external data is also relevant to understanding winter pressures. For instance, Public Health England releases a weekly bulletin on levels of influenza. Flu outbreaks can cause severe pressure on the NHS. The data for this winter shows that the number of acute respiratory outbreaks and hospitalisations from January onwards was higher than in winter 2016/17, the rate of GP consultations for flu-like illnesses was higher than usual levels.

Similar winter situation reports are not published in Scotland, Wales or Northern Ireland, although routine performance data can be accessed at the following links: • ISD Scotland • StatsWales • Department of Health Northern Ireland

Cover page image: George Hodan (public domain)

NHS winter pressures in England, 2017/18

Hospital accident & emergency attendances rose by 1.6% compared

with last winter. 22.9% of patients spent longer than 4 hours in A&E, compared

with 20.7% last winter and 6.2% in 2010/11. The number of A&E diverts for temporary respite was down on

last year.

Emergency admissions were up 6% on last year. The number of 12-hour waits

for admission hit a new high.

General & acute bed occupancy was 94.4% and was over 90% for all but four days this winter. On average, 20 hospital trusts had occupancy over 99% each day.

On average there were 1,100 fewer beds available each day than last winter. But there were also 1,500 fewer beds each

day lost to delayed discharges than last winter.

Norovirus bed closures were at their highest level for 3 years.

13,445 ambulances arrived at England's hospitals each day. One in eight

ambulance handovers were delayed by more than 30 minutes over the winter, peaking at one in four on 2nd January.

3% of handovers were delayed by more than an hour over the winter, with a peak

of 9% on 2nd January.

NHS 111 received an average of 43,000 calls per day. 27% of calls weren't

answered within 60 seconds, peaking at 60% on 24th December.

WINTER PATIENTS SPENDING OVER 4 HOURS INHOSPITAL A&E

6.2% 6.7%8.2% 7.5%

13.7%

16.3%

20.7%22.9%

2010/11 2013/14 2015/16 2017/18

NUMBER OF HOSPITAL TRUSTS OVER 99% BEDOCCUPANCY EACH DAY

0

10

20

30

40

20-Nov 11-Dec 01-Jan 22-Jan 12-Feb

AMBULANCE HANDOVERS DELAYED BYMORE THAN 30 MINUTES

0%

5%

10%

15%

20%

25%

20-Nov 11-Dec 01-Jan 22-Jan 12-Feb

Christmasperiod

3rd Jan

2nd Jan

4 NHS Winter Pressures 2017/18, England

2. Emergency Care

2.1 A&E attendances and waiting times Between December 2017 and February 2018, 3.7 million people attended major hospital accident and emergency departments in England.1 This is 1.6% higher than the same period last year – an extra 637 attendances per day across England. A&E attendances don’t peak in the winter – there were around 41,000 attendances per day over this period, compared with over 43,000 attendances per day in June and July last year – but the increased severity of cases can lead to greater pressure.

The percentage of patients spending longer than 4 hours in A&E (measured from arrival to departure or admission) was higher than in recent years, at 22.9% over the winter period. The number of patients seen in under four hours was also the lowest it has been in recent years. The table and chart below show trends on these measures.2

1 These departments are known as ‘type 1’ by NHS England, and are defined as those

offering a 24-hour consultant-led service. Typical ‘hospital A&E’ departments fall under this category. Data is also collected on attendances at walk-in-centres, minor injury units and other minor A&E facilities. That data isn’t discussed here.

2 Data in this section is taken from NHS England, Accident and Emergency Attendances and Admissions.

WINTER A&E WAITING TIMES IN ENGLANDDecember to February each year. Type 1 departments only

Year% Over 4

hoursNumber of

attendancesNumber over

4 hoursNumber under

4 hours2010/11 6.2% 3,347,000 207,000 3,140,0002011/12 6.7% 3,400,000 229,000 3,171,0002012/13 8.2% 3,437,000 282,000 3,155,0002013/14 7.5% 3,399,000 254,000 3,145,0002014/15 13.7% 3,438,000 471,000 2,967,0002015/16 16.3% 3,701,000 602,000 3,099,0002016/17 20.7% 3,642,000 754,000 2,889,0002017/18 22.9% 3,700,000 846,000 2,853,000

Patients spending longer than 4 hours in A&E each winter:

6.2%6.7%8.2%7.5%13.7%16.3%20.7%22.9%

2010/112011/122012/132013/142014/152015/162016/172017/18

Winter pressures data for all acute hospital trusts in England is available to browse in our downloadable tables.

5 Commons Library Briefing, 3rd April 2018

The tables below shows which NHS trusts had the highest and lowest percentage of patients spending over 4 hours in A&E. At 19 out of 137 trusts, four-hour waits accounted for more than one-third of attendances. At 13 trusts, less than 10% of attendees spent 4+ hours in A&E. The map on the following page shows data on each trust.

2.2 Emergency Admissions and Trolley Waits The number of emergency admissions to hospital over the winter period was also at its highest level, at 1.52 million, up from 1.44 million in 2016/17. This is an average increase of 944 emergency admissions per day across England.

Blackpool Teaching Hospitals NHSFT 51.9% Luton & Dunstable University Hospital NHSFT 3.1%The Hillingdon Hospitals NHSFT 45.7% Sheffield Children's NHSFT 3.5%Royal Cornwall Hospitals NHST 42.6% Yeovil District Hospital NHSFT 5.3%University Hospitals Of North Midlands NHST 41.4% Homerton University Hospital NHSFT 5.7%Norfolk & Norwich University Hospitals NHSFT 39.5% Birmingham Women's & Children's NHSFT 5.9%Worcestershire Acute Hospitals NHST 38.9% Alder Hey Children's NHSFT 6.5%Lancashire Teaching Hospitals NHSFT 38.9% Royal Surrey County Hospital NHSFT 6.8%Shrewsbury & Telford Hospital NHST 38.7% Dorset County Hospital NHSFT 7.2%Imperial College Healthcare NHST 37.4% Chesterfield Royal Hospital NHSFT 8.1%Portsmouth Hospitals NHST 37.0% Chelsea & Westminster Hospital NHSFT 8.3%

Highest percentage of 4+ hour waits Lowest percentage of 4+ hour waits

WINTER EMERGENCY ADMISSIONS AND TROLLEY WAITSDecember to February each year

Year

% 4 hour waits for

admission

Emergency admissions

4 hour waits for admission

12 hour waits for admission

2010/11 2.7% 1,295,939 34,888 352011/12 3.1% 1,298,407 40,809 182012/13 4.3% 1,293,341 55,269 812013/14 4.0% 1,340,293 53,493 1402014/15 9.1% 1,372,396 125,043 1,0202015/16 9.4% 1,435,495 134,951 3752016/17 13.7% 1,437,876 197,651 1,8802017/18 14.5% 1,522,855 220,694 1,914

Patients waiting longer than 4 hours for admission each winter:

2.7%3.1%4.3%4.0%9.1%9.4%13.7%14.5%

2010/112011/122012/132013/142014/152015/162016/172017/18

7 Commons Library Briefing, 3rd April 2018

The number of cases where patients waited over 4 hours to be admitted to hospital after a decision to admit was made – so-called ‘trolley waits’ – also rose, from 198,000 last winter to 221,000 this winter. There was also record number of 12-hour trolley waits, at 1,914 compared with 1,880 last winter. The percentage of all admissions which resulted in trolley waits of over 4 hours rose to its highest winter level, 14.5%.

The left-hand table below shows the trusts with the highest number of 12-hour trolley waits between December 2017 and February 2018. Two trusts, University Hospital of North Midlands and North Bristol, accounted for almost one-third of all 12-hour trolley waits in England.

The right-hand table below shows which trusts had the highest level of four-hour waits for admission, calculated as a percentage of total admissions. At eight trusts, more than one-third of those admitted waited longer than four hours after a decision to admit was made. At 35 of 137 trusts, however, less than 5% of those admitted had to wait over 4 hours.

2.3 A&E Diverts Between 20th November and 4th March there were 386 ‘accident and emergency diverts’. These are cases where a temporary divert is agreed from one A&E to another to provide temporary respite. Only diverts with a specific agreement between trusts are counted. NHS England says that “diversion of patients for respite should only happen in exceptional circumstances, where internal measures have not solved the underlying problem”.3 The level of diverts was below that seen last winter, and the bulk of diverts where concentrated in a handful of NHS trusts.

The chart below shows data comparing recent winters for 1 Dec to 28 Feb only, since data for previous years was published over different time periods.

3 NHS England Daily SitRep Guidance

University Hospitals Of North Midlands NHST 332 Blackpool Teaching Hospitals NHSFT 48.6%North Bristol NHST 255 The Princess Alexandra Hospital NHST 38.9%Blackpool Teaching Hospitals NHSFT 181 West Hertfordshire Hospitals NHST 38.5%Portsmouth Hospitals NHST 146 Worcestershire Acute Hospitals NHST 37.9%Southport & Ormskirk Hospital NHST 131 George Eliot Hospital NHST 37.4%Brighton & Sussex University Hospitals NHST 96 Southport & Ormskirk Hospital NHST 35.7%Stockport NHSFT 85 Warrington & Halton Hospitals NHSFT 35.6%University Hospitals Of Morecambe Bay NHSFT 77 Kettering General Hospital NHSFT 34.0%Oxford University Hospitals NHSFT 74 Isle Of Wight NHST 33.1%Shrewsbury & Telford Hospital NHST 51 Portsmouth Hospitals NHST 33.0%

Highest number of 12-hour trolley waits Highest percentage of 4-hour trolley waits

8 NHS Winter Pressures 2017/18, England

On 27th January, eight separate trusts registered A&E diverts – the highest number on any day this winter. The highest total number of total diverts was 14, on 1st January – largely because Gateshead trust registered 6 diverts on that day. The table below shows the ten trusts which registered the most A&E diverts between 20th November and 4th March.

3. Ambulances and NHS 111

3.1 Ambulance handover delays NHS England say that the handover of patients from an ambulance to a hospital emergency department should take no longer than 15 minutes.4 On 186,000 occasions this winter, an ambulance arriving at hospital was delayed by more than 30 minutes in handing over its patient(s) to the hospital. This amounts to 13% of all ambulance arrivals at hospital between 20th November and 4th March, - just over one in

4 NHS England, Ambulance Handover Letter Nov 2017

THERE WERE FEWER A&E DIVERTS BETWEEN DEC AND FEB THAN LAST YEAR, BUT MORE THAN PREVIOUS YEARS

211

287

224258 265

493

329

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Worcestershire Acute Hospitals NHST 105Gloucestershire Hospitals NHSFT 38York Teaching Hospital NHSFT 26Gateshead Health NHSFT 22County Durham & Darlington NHSFT 19Northumbria Healthcare NHSFT 14West Hertfordshire Hospitals NHST 12Brighton & Sussex University Hospitals NHST 12Wrightington, Wigan & Leigh NHSFT 10Portsmouth Hospitals NHST 10

Highest number of A&E diverts

9 Commons Library Briefing, 3rd April 2018

eight. Of these, 42,000 handovers were delayed for more than 60 minutes – 3% of all arrivals, or one in every 34.

Data on ambulance handover delays wasn’t collected in 2015/16 or 2016/17, but we can compare with earlier years. The chart below shows delays over 30 minutes for a comparable period covering December 1 to February 28 for each year in question.5 The number of delays in 2017/18 was substantially higher than previous years.6

In 2017/18 delays peaked in the period after Christmas. On 2nd January, one quarter of all ambulance arrivals were delayed for over 30 minutes and 9% were delayed for over 60 minutes. On 23 separate days, more than 15% of ambulances were delayed by over 30 minutes. 26th November had the lowest percentage of delays, at 8.2%.

At some NHS trusts the level of delays was substantially above average. The tables below show the trusts with the highest percentage of ambulance handovers delayed by 30+ minutes or 60+ minutes. At United Lincolnshire Hospitals trust, almost half of all ambulance arrivals were delayed by 30 minutes.

Six trusts reported zero 30-minute ambulance handover delays over the winter: Homerton Hospital (Hackney), Royal Free London, Alder Hey, North Bristol, Royal United Hospitals Bath, and Yeovil District Hospital. A further four trusts reported that less than 1% of handovers were delayed by 30+ minutes.

5 This means that the 2017/18 total (163,298) for Dec-Feb does not match the figure for

the entire winter quoted before (186,000, which covers 20 Nov to 4 Mar). 6 Note that for previous years the total number of ambulance arrivals was not published,

so it’s not possible to compare the percentage of arrivals delayed.

AMBULANCE HANDOVER DELAYS ROSE BY 72% COMPARED WITH 2014/15

58,00176,087

54,463

94,953

No data No data

163,298

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

10 NHS Winter Pressures 2017/18, England

Note that there some reported discrepancies between the number of delays registered by trusts, and the number registered by corresponding ambulance trusts.7

3.2 Ambulance response times The target that the most life-threatening ‘Category 1’ 999 calls should receive an emergency response at the scene in an average of seven minutes was not met in winter 2017/18. The table below shows monthly data covering the winter period. Only North East Ambulance Service met the seven minute target in each of these months. Values in this table are shaded, with darker shading indicating worse waiting time performance.

Because the classification of 999 calls and the waiting time targets for these services have recently changed, it’s not possible to compare trends in call volume or waiting times to previous years.

The 7-minute target is one of several target response times for ambulance services. See NHS England’s Ambulance Quality Indicators

7 See BBC News, ‘East of England Ambulance delay discrepancies 'worrying'', 8 Feb

2018

United Lincolnshire Hospitals NHST 48% United Lincolnshire Hospitals NHST 20%Lancashire Teaching Hospitals NHSFT 39% Lancashire Teaching Hospitals NHSFT 17%The Queen Elizabeth Hospital, King's Lynn, NHSFT 34% The Queen Elizabeth Hospital, King's Lynn, NHSFT 14%Worcestershire Acute Hospitals NHST 31% Portsmouth Hospitals NHST 12%The Princess Alexandra Hospital NHST 30% Southport & Ormskirk Hospital NHST 11%Kettering General Hospital NHSFT 30% North West Anglia NHSFT 10%East Lancashire Hospitals NHST 28% Wrightington, Wigan & Leigh NHSFT 10%North West Anglia NHSFT 27% York Teaching Hospital NHSFT 9%Portsmouth Hospitals NHST 27% Kettering General Hospital NHSFT 8%Sherwood Forest Hospitals NHSFT 26% Worcestershire Acute Hospitals NHST 8%

Ambulance handovers delayed over 30 mins Ambulance handovers delayed over 60 mins

Ambulance Service Dec-17 Jan-18 Feb-18

England 08m 52s 08m 19s 08m 16sEast Midlands 09m 38s 09m 19s 09m 27sEast 09m 12s 08m 35s 08m 42sLondon 07m 24s 07m 10s 07m 26sNorth East 06m 57s 06m 32s 06m 34sNorth West 11m 17s 09m 51s 08m 51sSouth Central 07m 42s 07m 04s 07m 05sSouth East Coast 08m 31s 07m 51s 08m 18sSouth West 10m 20s 09m 11s 09m 19sWest Midlands 07m 03s 06m 48s 07m 03sYorkshire 08m 12s 08m 10s 08m 07s

AVERAGE RESPONSE TIME TO CATEGORY 1 AMBULANCE CALLS (Target: 7 mins)

11 Commons Library Briefing, 3rd April 2018

for the full data, and our publication NHS Key Statistics for a discussion of the new targets.

3.3 NHS 111 NHS 111 is a non-emergency telephone line for healthcare advice. Throughout the winter, daily data is published on the activity and performance of these services, including the number of calls, the number that were answered within 60 seconds, and the number of callers that were advised to attend A&E.8

Call volume Between 20th November and 4th March, NHS111 services answered an average of 43,000 calls per day. This compares to an average of 20,500 emergency ambulance responses per day over the winter.

The highest number of calls answered was 86,400 on Saturday 23rd December, followed by 82,700 on Saturday 30th December. The number of calls on Saturday and Sundays was around double the number on weekdays.

Calls answered within 60 seconds Over the winter period, 73% of calls were answered within 60 seconds, compared with around nine in ten in winter 2016/17. However there was substantial variation between different days and different providers. The chart below shows the percentage of calls not answered within 60 seconds for England as a whole, each day over the winter.

8 Data in this section is taken from the NHS 111 time series data published by NHS

England.

12 NHS Winter Pressures 2017/18, England

On Christmas Eve, 60% of calls were not answered within 60 seconds – the highest percentage of any day this winter. This performance is substantially lower than the worst day in winter 2016/17, 27th Dec, when 36% of calls were not answered within 60 seconds.

Throughout the winter there was a weekly pattern, with 60-second answering times on Saturday tending to be worse than other days. As the chart shows, weekend response times became progressively worse throughout the winter, with the last Saturday of reporting (3rd March) seeing the worst performance of any day outside the Christmas and New Year period.

The table below shows which NHS 111 areas had the best and worst call answering timeliness over the winter period. South East Coast (excl. East Kent) had the lowest performance, answering only 52% of its calls within 60 seconds. By contrast, in East London & City, 91% of calls were answered within 60 seconds.

Looking at daily data, there were several cases where an NHS 111 service answered 10% or less of its calls within 60 seconds. These are shown below. The lowest performance, of 4% within 60 seconds, was registered by Oxfordshire NHS 111 on 24th December.9

9 Note that Mainland Ship NHS 111 covers Southampton, Hampshire, Isle of Wight and

Portsmouth.

South East Coast exc East Kent NHS 111 52% East London & City NHS 111 91%Bath/NE Somerset & Wiltshire NHS 111 60% Isle Of Wight NHS 111 91%Gloucestershire & Swindon NHS 111 61% South East London NHS 111 87%Bristol, N Somerset & S Gloucestershire NHS 111 61% Dorset NHS 111 87%West Midlands NHS 111 62% Outer North East London NHS 111 86%East Kent NHS 111 65% Yorkshire And Humber NHS 111 85%Hillingdon London NHS 111 69% North East England NHS 111 84%North West London NHS 111 70% Cornwall NHS 111 84%Norfolk incl. Great Yarmouth & Waveney NHS 111 70% Thames Valley NHS 111 81%North West inc Blackpool NHS 111 70% Staffordshire NHS 111 78%

Lowest % NHS 111 calls answered in 60 secs Highest % NHS 111 calls answered in 60 secs

Service Within 60 secs DateOxfordshire NHS 111 4% 24-DecBerkshire NHS 111 5% 24-DecSouth East Coast exc East Kent NHS 111 6% 24-DecMainland Ship NHS 111 8% 24-DecBuckinghamshire NHS 111 9% 24-DecEast Kent NHS 111 10% 30-Dec

WORST DAILY NHS 111 PERFORMANCE, WINTER 2017/18

13 Commons Library Briefing, 3rd April 2018

Callers recommended to attend A&E Over the winter period, an average of 3,000 callers to NHS 111 each day were advised to attend an accident and emergency department – around 1 in every 14 callers. This varied in different parts of England – in North Central London, 10.4% of callers were advised to attend A&E, while in Hertfordshire, 2.8% were advised to attend A&E.

Over the winter, the daily average A&E attendance level was 65,000 (including minor departments). So if each person advised to attend A&E as a result of an NHS 111 had attended, they would have comprised around 5% of attendances.

The proportion of NHS 111 callers advised to attend A&E was lower at weekends, suggesting that the average severity of a weekend call may be lower than a weekday call.

Ambulance dispatches Each day an average of 5,000 ambulances were dispatched by NHS 111 call handlers, meaning that around one in nine NHS 111 calls answered resulted in an ambulance dispatch. Again, this varied across England. In Devon, 16.9% of NHS 111 calls resulted in an ambulance dispatch, while in Hertfordshire the figure was 6.4%.

The proportion of NHS 111 calls resulting in an ambulance dispatch was lower at weekends, once again suggesting a lower average call severity at weekends.

4. Beds and capacity

4.1 Bed availability and occupancy Acute NHS trusts in England had fewer beds available on average this winter than in previous winters. Looking at the comparable period from December to February, there were around 1,100 fewer beds available than in 2016/17 (1.1%) and 2,300 fewer than in 2011/12 (2.3%).10

The highest number of beds available was 99,298 on Monday 19th February.

Average occupancy (excluding weekends) was 95.2% - higher than in 2016/17, but lower than in 2015/16. The table below shows the average number of beds available, and the average occupancy, for each winter period since 2011/12. This data covers December to February only.

10 This calculation excludes weekend data, since in years prior to 2015/16, bed

availability data was not published at weekends.

14 NHS Winter Pressures 2017/18, England

Occupancy levels followed a largely consistent pattern throughout the winter, with rates highest at the beginning of the week and lowest on Saturdays. There was also a dip in occupancy over the Christmas period. The highest occupancy was 96.1% on Tuesday 20th February, and the lowest was 84.2% on 24th December. There were only four days where occupancy was below 90%. Occupancy was over 95% on just over half of all days in the winter.

Occupancy varied substantially across the countries. Some NHS trusts were at or near full capacity on each day of the winter. The table below shows the trusts with the highest average occupancy between 20th November and 4th March.

Year Beds Occupancy2011/12 100,244 95.0%2012/13 100,561 94.8%2013/14 99,491 94.0%2014/15 100,541 94.9%2015/16 99,813 95.5%2016/17 98,960 94.9%2017/18 97,897 95.2%

December to February each year

AVERAGE GENERAL & ACUTE BEDS AVAILABLE/OCCUPIED

15 Commons Library Briefing, 3rd April 2018

There was a daily average of 20 trusts (out of 137 reporting data) above 99% bed occupancy and 75% above 95% occupancy. The chart overleaf shows how these numbers changed through the winter. The number of trusts over 99% peaked just after New Year, at 36 on Wednesday 3rd January. This number was almost matched on the last day of winter reporting, Sunday 4th March, at 34. The number of trusts over 95% occupancy also peaked on 3rd January at 98 – more than 70% of all trusts. Even on the lowest day of occupancy, 24th December, two trusts had occupancy over 99%: Walsall trust and Buckinghamshire trust.

The tables below show the trusts which spent the most days over 99% occupancy (left) and 95% occupancy (right). There were 105 days in the winter data period, meaning that Basildon & Thurrock trust spent each day over 95%, and that Walsall trust spent all but 11 days over 99%.

Walsall Healthcare NHST 99.7%North Middlesex University Hospital NHST 99.5%The Princess Alexandra Hospital NHST 99.3%The Hillingdon Hospitals NHSFT 99.3%Northampton General Hospital NHST 99.2%Basildon & Thurrock University Hospitals NHSFT 99.1%James Paget University Hospitals NHSFT 99.1%Kettering General Hospital NHSFT 99.0%King's College Hospital NHSFT 99.0%Worcestershire Acute Hospitals NHST 99.0%

Highest average bed occupancy

16 NHS Winter Pressures 2017/18, England

Escalation beds An escalation beds are temporary beds to provide extra capacity. They are usually closed as they are additional to the substantive, funded and staffed bed stock. So a higher number of escalated beds shows a high level of pressure on a trust.

Before the Christmas period in 2017 the number of escalation beds open was around 2,500 per day in England. After Christmas this rose to around 4,500 per day. These levels are similar to winter 2016/17. However, in 2016/17 the number of escalation beds began to gradually fall in February, suggesting a decline in pressure. In 2017/18, the number of escalation beds remained constant until the end of the winter reporting period, suggesting that pressure did not abate.

The table below shows the trusts where escalation beds made up the largest proportion of total available beds between 20th November and 4th March

Walsall Healthcare NHST 94 Basildon & Thurrock University Hospitals NHSFT 105North Middlesex University Hospital NHST 86 Northampton General Hospital NHST 104The Princess Alexandra Hospital NHST 84 Worcestershire Acute Hospitals NHST 104The Hillingdon Hospitals NHSFT 83 Walsall Healthcare NHST 103James Paget University Hospitals NHSFT 76 North Middlesex University Hospital NHST 103Basildon & Thurrock University Hospitals NHSFT 75 The Hillingdon Hospitals NHSFT 103Kettering General Hospital NHSFT 73 Kettering General Hospital NHSFT 103King's College Hospital NHSFT 72 King's College Hospital NHSFT 102Northampton General Hospital NHST 69 Wirral University Teaching Hospital NHSFT 102Croydon Health Services NHST 68 London North West Healthcare NHST 101

Most days over 99% bed occupancy Most days over 95% bed occupancy

17 Commons Library Briefing, 3rd April 2018

Beds occupied by long stay patients This new measure for 2017/18 presents the number of beds on each day that were occupied by patients who had been in hospital for over 7 days and over 21 days. As NHS Providers note, this doesn’t distinguish between those still needing care and those whose discharge has been delayed. It also may be influenced by norovirus, since “patients with norovirus or on an infected ward can’t be discharged back to anywhere with other vulnerable people, for example a care home, even if they no longer require hospital care.”11

On average over the winter period, 45.7% of available beds were occupied by long stay patients over 7 days, and 17.7% were occupied by long stay patients over 21 days. This fluctuated relatively little between 20th November and 4th March, but it is notable that the very highest levels of long stay patients – 48.7% over 7 days and 18.8% over 21 days - was observed on the final day of winter reporting, Sunday 4th March.

The tables below show the trusts which had the highest percentage of their bed days occupied by long stay patients across the whole winter period.

11 NHS Providers, Winter Pressures: Getting Underneath the Data

Barnsley Hospital NHSFT 18%The Whittington Hospital NHST 17%Walsall Healthcare NHST 13%Aintree University Hospital NHSFT 13%Great Western Hospitals NHSFT 11%Chelsea & Westminster Hospital NHSFT 10%Bedford Hospital NHST 10%Croydon Health Services NHST 9%Harrogate & District NHSFT 9%North Middlesex University Hospital NHST 9%

Highest reliance on escalation beds

Homerton University Hospital NHSFT 83% Homerton University Hospital NHSFT 48%Northampton General Hospital NHST 65% Northampton General Hospital NHST 32%Leeds Teaching Hospitals NHST 61% Leeds Teaching Hospitals NHST 29%University Hospitals Birmingham NHSFT 61% Portsmouth Hospitals NHST 28%University Hospital Southampton NHSFT 60% Birmingham Women's & Children's NHSFT 28%Portsmouth Hospitals NHST 59% Kettering General Hospital NHSFT 28%Harrogate & District NHSFT 58% Barts Health NHST 27%The Whittington Hospital NHST 58% Manchester University NHSFT 26%Oxford University Hospitals NHSFT 58% Salford Royal NHSFT 25%Mid Cheshire Hospitals NHSFT 58% Oxford University Hospitals NHSFT 25%

Beds occ'd by long stay patients (>7 days) Beds occ'd by long stay patients (>21 days)

18 NHS Winter Pressures 2017/18, England

4.2 Delayed discharges Delayed discharges, also known as ‘delayed transfers of care’, occur when a patient is ready to leave their current level of care but are delayed in doing so. This can lead to beds being unavailable for patients waiting to be admitted, so can cause issues with patient flow. In December and January, around 3.7% of possible bed days were lost to delayed discharges across England.12

After reducing delayed discharges formed a key part of the NHS England Mandate for 2017/18, the number of delays fell by around a quarter compared with last winter, from 6,338 per day to 4,800 per day. Delays due to social care fell by 30% and delays due to the NHS fell by 21%. Nevertheless, the level of delays was higher than this winter than in 2014-15 or 2013-14.13

The tables below show the acute providers which lost the largest percentage of possible overnight bed days to delayed discharges in December and January.

12 This is calculated using data for all NHS providers where data on the number of beds

available overnight is available. 13 Data in this section is taken from NHS England’s Delayed Transfers of Care data.

NHS Social Care Both

2013-14 3,821 2,617 969 235 2.8%2014-15 4,668 3,129 1,219 320 3.5%2015-16 5,056 3,083 1,631 342 3.9%2016-17 6,338 3,573 2,257 507 4.9%2017-18 4,800 2,833 1,592 375 3.7%

Year TotalResponsible organisation Estimated

bed days

ON AVERAGE, 1,500 FEWER BEDS WERE LOST TO DELAYED DISCHARGES EACH DAY THAN LAST YEAR

0

2,000

4,000

6,000

2013-14 2014-15 2015-16 2016-17 2017-18

NHS Social Care Both

19 Commons Library Briefing, 3rd April 2018

The tables below show delayed discharges in December and January apportioned to the local authority where the patient is resident, and calculated as a crude rate per 1,000 resident population. Plymouth, Cumbria and Hampshire had the highest rates of delayed transfers, with Sunderland, Sandwell and Barking having the lowest.

4.3 Beds closed due to norovirus Norovirus, which causes diarrhoea and vomiting, often peaks in winter, and NHS trusts take measures to contain the infection. When a case is identified, it is often necessary to close not only the bed occupied by the infected patient, but other beds in the same ward.

The level of norovirus bed closures was higher this winter than in 2015/16 and 2016/17, but lower than in previous years. The chart below shows the average daily number of bed closures across England.14

14 This excludes weekends for 2016/17 and 2017/18 since data from previous years did

not cover weekends.

Burton Hospitals NHSFT 8.9%North Cumbria University Hospitals NHST 8.1%University Hospital Southampton NHSFT 7.6%Cambridge University Hospitals NHSFT 7.6%South Warwickshire NHSFT 7.2%Oxford University Hospitals NHSFT 7.1%Lancashire Teaching Hospitals NHSFT 6.9%Milton Keynes University Hospital NHSFT 6.8%Hampshire Hospitals NHSFT 6.7%Bolton NHSFT 6.7%

BED DAYS LOST TO DELAYED DISCHARGES

Plymouth 14.6 per 1,000 Sunderland 1.2 per 1,000Cumbria 13.9 Sandwell 1.2Hampshire 10.9 Barking & Dagenham 1.2Cornwall 10.4 Merton 1.3Oxfordshire 10.4 Sutton 1.4Stoke-On-Trent 10.2 Waltham Forest 1.4Dorset 10.0 Bradford 1.4Bury 9.9 Luton 1.5Sheffield 9.4 Barnsley 1.6Bristol 9.2 County Durham 1.6

HIGHEST RATES OF DELAYED DISCHARGES LOWEST RATES OF DELAYED DISCHARGES

20 NHS Winter Pressures 2017/18, England

As the chart below shows, there were three main peaks in norovirus closures this winter: around 10th December; around 4th January; and around 21st February. Closures also spiked on the final day of reporting, 4th March.

The tables below show the trusts that had the highest levels of norovirus bed closures this winter. The left table shows the highest number of closures, while the right table shows the number of closures measured against daily bed availability.

Average daily closures

NOROVIRUS BED CLOSURES WERE HIGHER THAN THE LAST TWO WINTERS BUT DOWN ON PREVIOUS YEARS

2,186

1,432

810

1,197

634 630778

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

NOROVIRUS BED CLOSURES WERE HIGHEST IN EARLY DECEMBER

0

200

400

600

800

1,000

1,200

1,400

20 Nov 04 Dec 18 Dec 01 Jan 15 Jan 29 Jan 12 Feb 26 Feb

21 Commons Library Briefing, 3rd April 2018

4.4 Cancelled operations As was widely reported, NHS England asked trusts to cancel non-urgent operations for part of the winter.15 These will be unlikely to appear in NHS England’s routine publications on cancelled operations, because these measure only operations which were cancelled at the ‘last minute’ (i.e. on the day of the operation).

NHS England recently published an assessment of cancelled non-urgent operations in January 2018, concluding that there were 22,800 fewer elective admissions compared with the previous January. This amounts to a fall in activity of 3%.16

Note, however, that these cancellations were reported in some parts of the country to have recurred during later parts of the winter, up to the end of March.

15 See e.g. NHS England, Operational update from the NHS National Emergency

Pressures Panel, 2 Jan 2018 16 NHS England, Deferred Elective Activity in January 2018

St George's University Hospitals NHSFT 4,878 Weston Area Health NHST 12%Taunton & Somerset NHSFT 4,503 Kingston Hospital NHSFT 9%Kingston Hospital NHSFT 3,826 Taunton & Somerset NHSFT 7%King's College Hospital NHSFT 3,319 St George's University Hospitals NHSFT 5%Weston Area Health NHST 3,318 Yeovil District Hospital NHSFT 5%University Hospitals Of Leicester NHST 2,337 The Rotherham NHSFT 5%The Rotherham NHSFT 2,247 The Princess Alexandra Hospital NHST 4%Northumbria Healthcare NHSFT 2,161 Northern Lincolnshire & Goole NHSFT 3%Northern Lincolnshire & Goole NHSFT 2,050 Milton Keynes University Hospital NHSFT 2%Yeovil District Hospital NHSFT 1,959 King's College Hospital NHSFT 2%

Highest bed days lost to norovirus closures Highest % bed days lost to norovirus

BRIEFING PAPER Number 8210 3rd April 2018

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