Winter is always a difficult time in the NHS. Cold weather brings a potent mix of flu, winter vomiting bugs and respiratory conditions that affect patients and staff alike. The end result, year after year, is that hospitals get fuller, GPs are swamped, and patients wait longer for care.

If there was any doubt of how extreme these pressures can get, a quick look at last year’s data shows that nearly all available beds were occupied at the height of winter (Figure 1) even as 18,000 patients a day on average were coming to hospital in need of an emergency admission. As an NHS surgeon once told me: ‘The difference between a few percentage points on bed occupancy may not sound like a lot, but it’s the difference between a system that feels in control, and a system that feels completely out of control.’

Figure 1: On the most pressurised day of winter 2018/19 nearly all NHS hospitals were operating above recommended bed-occupancy levels

On 6 February 2019 almost all hospitals (98 per cent) had bed-occupancy levels of over 85 per cent, while on 24 December 2018 it was only a third.

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And looking ahead to this winter, there is a renewed risk that a combination of Brexit and ennui will stop NHS winter pressures from receiving the scrutiny and attention they deserve. So here are five reasons why we should not lose sight of the pressures as the NHS heads into the winter months.

 1. The NHS is heading into winter in unusually bad shape

Less than two years ago the then Prime Minister, Theresa May, said the NHS was heading into winter better prepared than ever before. That claim is unlikely to be made this year. The NHS has not seen the usual improvement in waiting time performance it usually experiences over summer, with performance getting worse since last year (Figure 2). So it heads into winter with A&E performance at its worst level since current records began, 4.6 million people on hospital waiting lists and with 100,000 vacant staff posts.

Figure 2: The NHS has not seen its usual pre-winter recovery in A&E performance

On 6 February 2019 almost all hospitals (98 per cent) had bed-occupancy levels of over 85 per cent, while on 24 December 2018 it was only a third.

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In the past, the pre-winter period would be used to prepare extra capacity for emergency admissions to hospital by opening additional escalation wards and cancelling planned surgery ahead of winter. But this year, even if beds could be opened there are not enough people to staff them, and cancelling yet more operations is even less palatable when waiting lists are already eye-wateringly high. All of which leaves the NHS increasingly boxed-in as winter pressures march closer.

 2. No extra funding to help the NHS through winter

For most of this decade the NHS has been dependent on extra funding to get through winter. This funding, usually released late in the year as winter approached, was used to open and staff extra hospital wards; buy additional care home-bed capacity for patients in hospital; and extend GP opening hours.

But the announcement of a general election and subsequent cancellation of the Autumn Budget 2019 means the NHS will be heading into winter without any extra government funding for the first time in recent memory (Figure 3). And while adult social care services were allocated an extra £240 million of financial support to reduce pressures on the NHS, this temporary financial fix is a far cry from the substantial funding reform needed to put these services on a more resilient footing.

That leaves local and national NHS organisations with some unpalatable options. Funding that was earmarked for other parts of the NHS could be reallocated for winter; NHS organisations could enhance services by spending money they do not have (assuming staff can be found to support these services); or the NHS could live within its current budgets and see patients wait even longer for care.

A new government in January 2020 might decide that a rapid injection of winter funding is needed. But for the NHS and winter funding, 2019/20 would be a case of ‘too little, too late’ rather than ‘better late than never’.

Figure 3: The NHS will not receive winter funding for the first time in eight years

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 3. More pressure from high levels of flu

Flu outbreaks create pressure on all parts of the NHS during winter – creating greater demand for telephone advice, GP consultations and admissions to intensive care units in hospital. Last year the United Kingdom was relatively lucky to see only low to moderate levels of flu, and flu activity has remained below baseline levels so far this winter.

But although flu outbreaks in Australia are not always a good predictor of what the United Kingdom can expect, most clinicians I speak to are anxious about the prospects of the punishing early and severe flu season in Australia (Figure 4) being mirrored in the United Kingdom and putting further strain on services that are already thinly stretched.

Figure 4: The total number of confirmed cases of flu in Australia this year is the highest in the past decade

Cumulative total of lab-confirmed influenza cases

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 4. The pension crisis reaches A&E departments

It is not news to say the NHS is in the midst of a staffing crisis. But this crisis – which includes more than 2,800 advertised staff vacancies in A&E services in 2018/19 – has been exacerbated by recent changes to pension tax rules that are leading NHS staff to turn down extra locum shifts or contemplate early retirement. A recent Royal College of Emergency Medicine survey shows the vast majority of surveyed A&E doctors think these changes will have a detrimental impact on patient safety – and there are even some reports of rotas for trauma care coming under pressure.

The pension crisis is clearly rising up the agenda – that much is clear from recent government consultations, rapid re-consultations, rumoured announcements, and the encouragement from national NHS leaders to use flexibilities in the current pension rules to allows clinicians to take on extra shifts.

But this is a crisis that was created by a change to government policy, which the government has then been slow to react to. Given the glacial pace at which substantive tax changes can be made, any promises to ‘fix’ the pensions issue for both clinical and managerial staff will only have a substantive impact next year at the earliest, rather than during the coming winter.

 5. Brexit and a general election

The United Kingdom is preparing for its first December general election since 1923, and (another) new Brexit deadline at the end of January. As an important public service and key election issue, this means the NHS will remain close to the front pages even if the usual winter performance data will be held back under pre-election rules.

But more importantly, NHS leaders and staff will somehow need to find the capacity to simultaneously plan for two concurrent crises: a winter surge in activity and a no-deal Brexit. Although some elements of Brexit planning have been paused, local NHS bodies have been told the preparations for a no deal outcome must continue. This preparation, vital as it is, comes with a considerable opportunity cost that needs to be recognised as services come under traditional winter pressures over the coming months.