The Impact of Winter on the

NHS in London

Richard McEwan / Nick Vincent

EPRR Team

Operations and Delivery Directorate

16 July 2013

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Headline News

A more complicated picture – one example

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The NHS in London

• 3 “patches” or Local Areas – NW, South and NE&C

• 32 CCGs

• 23 acute trusts – includes 47 acute sites, with 33 EDs

• 27 UCCs, WICs etc

• 15 specialist and MH trusts

• Circa 1,500 GP practices

• Circa 13,000 general and acute beds, rising to circa 13,800 during winter through

escalation capacity

• Annual ED attendances (type 1) of 2,728,478 of which 946,624 during winter, all

types 4,439,124 of which 1,607,028 (all types) during winter

• Annual admissions via ED of 650,641 of which 220,020 during winter

• Annual LAS conveyances of 819,423, of which 275,663 during winter

• Total London NHS budget £15,640 million

• Covers a population of circa 8.308 million

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The impact of cold weather….

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Not just about this stuff….

Photo courtesy of NASA

The Impact of cold weather

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• There is an increase in admissions for respiratory disease 12 days after a

drop in temperature

• GP consultations increase up to 19% for every 1 C drop in temperature

below 5 C.

• In Britain a cold spell during a mild winter is followed:-

I. two days later by a sudden rise in heart attacks;

II. five days later there is a big rise in the number of strokes; and twelve

days later by a big rise in respiratory illness.

• Health services will also see a significant rise in attendances for slips, trips

and falls following adverse weather (e.g. snow and ice) conditions.

Source – Yorkshire & Humber Public Health Observatory – Data bites

Cold Weather & the Health and Social Care System

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• Fall in temperature

• Snow/melt/freeze/ice = immediate increased attendance – falls and trauma

• Low ambient temperature = 2-3 day lag = cardiac, respiratory, stroke,

hypothermia cases

• Increased – viral illnesses, opportunistic respiratory infections

• Calls to LAS = increased transfers to ED = delayed handover (last winter

11,500 patients waited 30 mins or over for handover)

• Attendance to Primary Care – GPs, Walk-in Centres, Urgent Care Centres

= increased medical referrals

• Emergency medical admissions (last year 34% during winter) above

medical bed establishment = increased bed outliers = “safari” ward rounds

= extended LOS and delayed discharges

• Increased demands on social work assessment = potential delays

• Increased demands on post-hospital care packages and rehab beds =

DTOC (last winter nearly 25,000 bed days) (and probably more significantly

increased medically fit for discharge patients)

Other factors

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• The Norovirus season = decreased capacity in hospital (last winter

13,400 beds closed) and residential/nursing homes due to

isolation measures.

• Regional and sub-regional ED capacity pressures = redirections =

patients out of area.

• London’s periphery – increased transfers in and out of London

• Impact on the NHS infrastructure of winter disruption – power,

water, and other utilities

• Transport issues – inclement weather, delayed discharges

• Staffing issues – seasonal influenza

Cold Weather & the Health and Social Care System

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Assurance process

• Comprehensive whole system assurance process – “winter” planning

round

• Pre-Winter Exercise process

Management processes

• Winter teleconferences – scaled up according to pressure

• Whole system approach – Urgent Care Network/Boards

• Day-to-day surge capacity managed by CCGs or CSUs

• Clear escalation processes

• Breach Reports – 12 hour trolley waits, 60 minute LAS handover

delays

• Capacity Management System

• LAS - REAP and DMP

The London Overview

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Indicator 2011/12 2012/13 Variance

2011/12 vs

2010/11

Variance

2012/13 vs

2011/12

A&E Divert 125 98 -8 -27

Beds closed – norovirus 22833 13365 12781 -9468

Beds unavailable –

DTOC

26458 24805 3307 -1653

Handover delays – 30-60

mins

3902 4180 355 278

Handover delays – 60

mins +

1260 429 324 -831

Data source: Winter Daily Sitrep (Data warning – this information is non validated) and LAS HAS Portal (validated data)

Proportion of beds occupied to beds available - Winter

Hospital Lowest Highest Average

Ealing 99.0 100.0 100.0

GSTT 97.0 100.0 98.7

North Middx 91.0 100.0 98.6

Royal Free 91.9 100.0 98.2

Kings College 95.0 100.0 97.9

Lewisham 88.7 100.0 97.5

Kingston 89.3 100.0 96.6

The Whittington 80.0 100.0 95.8

Imperial 81.6 98.7 91.7

West Middx 79.7 98.4 90.2

UCLH 81.6 100.0 85.7

Average 89.3 99.7 96.4

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Occupancy

• The consistently high proportion of beds occupied may account for the

poor level of performance against the ED standard

• The gold standard for bed occupancy is 85% (recent updated analysis

suggests up to 91% may be ok) - anything consistently above this will

lead to issues in the flexible use of the bed base

• Only 1 trust in London (excluding specialist centres had an average

figure at 85% and 3 others below 91% during the winter last year.

• The lowest figures are only achieved over Christmas and New Year.

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In conclusion

• System under considerable pressure during the winter

• ED should not be the default destination

• Better “whole system” planning required

• Breakdown in any one part of the system will lead to domino effect

elsewhere

• Patients present 7 days a week – service availability needs to match

• Prevention is better than cure

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