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BRIEFING PAPER Number 7057, 20 April 2017

NHS Winter Pressures 2016/17: summary

By Carl Baker

Contents: OPEL Pressure Levels Bed Occupancy A&E Diverts A&E Performance Norovirus NHS 111 RCEM Winter Flow Project

2 NHS Winter Pressures 2016/17: summary

Introduction Between 1 December 2016 and 12 March 2017, NHS England published daily situation reports on winter pressures facing acute hospital trusts. These covered pressures such as pressure levels, accident and emergency diverts, bed days lost to Norovirus closures and general and acute bed occupancy. In addition, performance indicators for NHS 111 were published.

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”.1

This briefing summarises the data for winter 2016/17, making comparisons to previous years where appropriate.

Operational Pressure Alerts Operational Pressure Escalation Levels (OPEL) are a way for NHS trusts to report levels of pressure consistently. There are 4 OPEL levels, defined as follows:2

Operational Pressure Escalation Levels (OPEL)

OPEL 1: organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Additional support is not anticipated.

OPEL 2: The local health and social care system is starting to show signs of pressure. The Local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation.

OPEL 3: The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required.

OPEL 4: Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. All available local escalation actions taken, external extensive support and intervention required.

The winter situation reports give daily information on which trusts are reporting OPEL 3 or OPEL 4 (i.e. either “major pressures” or “unable to deliver comprehensive care”). This system is not comparable to

1 NHS England, Winter Sitrep Guidance 2 NHS England, Operational Pressure Escalation Levels Framework

3 Commons Library Briefing, 17 March 2017

reporting from previous years, when trusts were asked to report if they had experienced “serious operational pressures”.

In total, 93 trusts reported OPEL 3 (“major pressures compromising patient flow”) on at least one day during the winter. That’s just over 60% of the 152 trusts reporting data. 55 trusts reported OPEL 3 on more than 10 occasions. Meanwhile, 37 trusts reported OPEL 4 (“unable to provide comprehensive care”) on at least one day – a quarter of all trusts. Eight trusts reported OPEL 4 on more than ten days throughout the winter.

The chart above shows the total number of trusts reporting OPEL 3 or 4 on each day during the reporting period. Pressures peaked on January 9th, with 62 trusts reporting OPEL 3 or 4 on that day.

The graphic below gives a daily overview of OPEL levels for the trusts which experienced the most pressure throughout the winter. Salisbury NHS Foundation Trust had the highest total number days at either OPEL 3 or 4 (57 out of 74 total). The other ten trusts listed here are those which had the highest number of days at OPEL 4. University Hospitals Of Leic ester NHS Trust spent 29 days at OPEL 4 – the most of any trust.

The graphic shows how different trusts experienced different patterns of pressure. For instance, all of East Sussex Healthcare NHS Trust’s OPEL 4 days came at the end of the winter. Trust names are truncated in this graphic.

The map on the following page shows which trusts reported OPEL 3 or 4 during the winter period.

Trusts reporting operational pressures at level 3 or 4

Daily data, 1 Dec 2016 to 12 Mar 2017

0

20

40

60

01-Dec 16-Dec 03-Jan 18-Jan 03-Feb 21-Feb 09-Mar

Operational Pressure Escalations in England and selected NHS Trusts, December 2016 to March 2017

Key: : OPEL 4 : OPEL 3 : Total trusts reporting OPEL 3 or 4 (darker shading = more)

OPEL 3 indicates major pressures compromising patient flow. OPEL 4 indicates trusts unable to provide comprehensive care and risks to patient safety.Each square represents a day of reporting. If a square is shaded red or brown, this means that an OPEL 3 or 4 alert was registered on that day.The England line measures the total number of OPEL 3 or 4 alerts in the country on that day. Darker shading indicates a higher number.

England

SalisburyLeicesterCornwallPortsmouthSurrey & SussexWest HertfordshireEast SussexPrincess Alexandra (Harlow)Weston AreaEast & North Hertfordshire

December January February March

5 Commons Library Briefing, 17 March 2017

Bed Occupancy The winter situation reports record information on bed occupancy for general & acute beds, adult critical care beds, neo-natal intensive care beds, and paediatric intensive care beds. This section summarises the data for general & acute beds.

As the chart to the right shows, bed occupancy in 2016/17 was broadly in line with previous years. At some points in January and February, occupancy was above previous years. Note that this average includes specialist trusts which typically have lower occupancy, so may understate the situation in acute trusts.

The charts below show the number of trusts with high bed occupancy on each day through the winter. On 9th January, 108 of 152 trusts had bed occupancy over 95%. This is also the day that OPEL 3 and 4 alerts peaked (see above). The number of trusts over 97% occupancy peaked on 6th February at 81. The number of trusts with bed occupancy over 99% also peaked on 9th January, at 46. Throughout January and February, there were regularly more than 20 trusts at over 99% occupancy.

Bed Occupancy (general & acute), 1 December to 12 March

ABOVE 95% OCCUPANCY: number of trusts, daily

ABOVE 97% OCCUPANCY: number of trusts, daily

ABOVE 99% OCCUPANCY: number of trusts, daily

0

20

40

60

80

100

120

01-Dec 15-Dec 29-Dec 12-Jan 26-Jan 09-Feb 23-Feb 09-Mar

0

20

40

60

80

01-Dec 15-Dec 29-Dec 12-Jan 26-Jan 09-Feb 23-Feb 09-Mar

0

20

40

01-Dec 15-Dec 29-Dec 12-Jan 26-Jan 09-Feb 23-Feb 09-Mar

NHS England expects the daily bed

occupancy snapshot to take place at 8am

or 9am.

General & acute bed occupancy, England, 2012-2017 (weekday average)

2016/17

Previous years

85%

90%

95%

100%

01-Dec 22-Dec 12-Jan 02-Feb 23-Feb

7 Commons Library Briefing, 17 March 2017

Accident and Emergency Diverts The winter situation reports contain information on temporary diverts agreed between A&E departments 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 A&E diverts was higher in 2016/17 than previous years in almost every week of the winter, as the chart below shows. Overall, there were 84% more diverts than in 2015/16 (comparing only those parts of the winter for which data was available in both years).

44 NHS trusts – just under 30% of trusts reporting data – reported at least one A&E divert during the winter. 15 trusts reported more than 10 diverts.

The number of A&E diverts peaked in mid-January (week ending 15th), at 52.

The chart below shows a comparison to previous years. Note that previous years had different reporting periods, which is why some lines begin and end at different points.

The map on the following page shows the trusts which reported the most A&E diverts in winter 2016/17.

3 NHS England Daily SitRep Guidance

Accident and Emergency Diverts, weekly, England, 2012-2017

2016-17

Previous years

0

10

20

30

40

50

60

13-Nov 04-Dec 25-Dec 15-Jan 05-Feb 26-Feb

9 Commons Library Briefing, 17 March 2017

Accident and Emergency Performance The Winter Situation Reports contain no information on the usual A&E performance measures (i.e. 4 hour waits). The information below is taken from NHS England’s routine A&E data publications, which give monthly data for December, January and February.

4 hour waits 21% of patients at England’s emergency departments (type 1 A&E) spent longer than 4 hours in A&E between December and February. This compares with 16% in winter 2015/16, 14% in winter 2014/15, and 7% in winter 2013/14. In total there were 750,000 waits of over 4 hours between December 2016 and February 2017.

The map on the following page shows the trusts with the highest level of 4-hour waits over the winter.

12 hour waits A recent one-off data release showed that there were 110,000 A&E attendances lasting 12 hours or more between November and January. Based on attendance data published by NHS England, it is likely that around 3% of attendances at major departments over the winter lasted for over 12 hours. The number of 12 hour attendances at major A&E departments almost doubled compared with the same period last year.

University Hospitals of Leicester had the highest number of 12 hour waits, at 9,146 over the three month period. The table below compares these figures with the attendances as published in the provisional quality indicators to give an estimated percentage of attendances that lasted for 12+ hours between November and January.

NHS Digital advises that there are “known data quality issues with the duration to departure variable in HES data, for example a midnight departure time may be used as a default time setting by some providers.”

A&E attendances with a duration of 12 hours or moreNovember 2016 - January 2017, England

NHS Trust NumberEstimated % of all

attendancesUniversity Hospitals of Leicester 9,146 15%Weston Area 1,169 9%University Hospitals of North Midlands 3,936 9%Royal Liverpool & Broadgreen Hospitals 2,210 8%The Princess Alexandra Hospital 1,850 7%Imperial College Healthcare 4,389 7%Medway 2,038 7%East Sussex Healthcare 1,822 7%Lewisham & Greenwich 3,540 7%Worcestershire Acute Hospitals 2,655 6%

A&E waiting times: patients spending longer than 4 hours

Winter: December - February inclusive

6% 7%8% 7%

14%

16%

21%

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

A&E attendances of 12 hours+

0

20,000

40,000

60,000

Nov Dec Jan

2016/17

2015/16

11 Commons Library Briefing, 17 March 2017

Beds closed due to Norovirus/D&V symptoms NHS trusts are required to report the number of beds each day that are closed due to diarrhoea & vomiting/norovirus-like symptoms.

The number of norovirus bed closures in 2016-17 was relatively high in December and early January. By the end of the winter, however, closures had fallen below the levels seen in previous years.

The chart below shows weekly data with a comparison to previous years. Note that previous years had different reporting periods, which is why some lines begin and end at different points.

119 trusts – over three-quarters of those reporting data – had at least one bed closure due to norovirus during the winter. 23 trusts reported over 1,000 norovirus bed closures across the whole winter. 47 trusts reported a number of closures equivalent to their total number of daily beds available (i.e. the equivalent of a whole day’s beds lost due to norovirus across the winter).

The map on the following page shows the trusts which had the highest levels of norovirus closures in winter 2016/17. Because different trusts have a different number of beds, this is calculated by dividing the total number of bed closures for each trusts by the average number of beds available each day. So a value of 1 would indicate that the trust had the same number of bed closures between December 1st and March 12th as its average daily bed availability during that period (i.e. it lost the equivalent of 1 day’s bed availability to norovirus closures).

Bed days lost to norovirus closures, weekly, England, 2012-2017

2012/13

2016/17

Other recent years0

4,000

8,000

12,000

16,000

13-Nov 11-Dec 08-Jan 05-Feb 05-Mar

13 Commons Library Briefing, 17 March 2017

NHS 111 performance 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.

Overall, around nine in ten calls this winter were answered within 60 seconds. The lowest performance was on 27th December, when 36.4% of calls were not answered within 60 seconds. Outside of the Christmas period, the lowest performance tended to be at weekends, at the highest performance during the week.

The chart below shows the NHS 111 services with the highest and lowest performance throughout the winter. Performance was lowest in the North West, with 74% of calls answered within 60 seconds. The next-lowest performing NHS 111 service was East Kent, at 83%. At the broader level of NHS regions, performance was highest in London (94%) and lowest in the North (86%).

NHS 111 calls not answered within 60 seconds, England, Nov 28th to Mar 12th

0%

10%

20%

30%

40%

28-Nov 18-Dec 07-Jan 27-Jan 16-Feb 08-Mar

NHS 111 called answered within 60 seconds Nov 28th to Mar 12th, England

Highest performance Lowest performanceEast London & City 97% North West incl. Blackpool 74%North West London 95% East Kent 83%Milton Keynes 95% Cornwall 84%South East London 95% Oxfordshire 85%Inner North West London 95% Dorset 85%Hillingdon (London) 95% Buckinghamshire 86%Suffolk 94% Berkshire 86%North Central London 94% West Midlands 86%Bristol, North Somerset & S Gloucestershire 94% So'ton/Hampshire/Isle of Wight/Portsmouth 86%Bath/NE Somerset/Wiltshire 94% South East Coast excl. East Kent 86%

Days with the lowest performance% calls not answered within 60 seconds

Tuesday 27 Dec 36.4%

Monday 02 Jan 33.3%

Saturday 10 Dec 23.7%

Monday 26 Dec 22.5%

Sunday 01 Jan 21.0%

Days with the highest performance% calls not answered within 60 seconds

Wednesday 21 Dec 1.8%

Friday 23 Dec 2.3%

Thursday 22 Dec 2.8%

Friday 13 Jan 2.9%

Tuesday 17 Jan 3.9%

14 NHS Winter Pressures 2016/17: summary

Patients recommended to attend A&E

Of those who called NHS 111 over the winter, 7% were recommended to attend A&E. This percentage peaked at 8.9% on 30th November and 22nd February (although the raw number recommended to attend A&E peaked on 2nd January). If all patients had followed the recommendation, then these attendances would have accounted for around 5% of total A&E attendances.

The percentage recommended to attend A&E tends to be substantially lower on Saturdays and Sundays than on weekdays, which may indicate that NHS 111 serves as a first point of call for non-urgent cases on days when primary care services are not so readily available.

The percentage of calls where A&E was recommended was highest in Luton (11.3%) and North Central London (11.2%). It was lowest in Leicestershire (3.9%). Looking at wider NHS regions, the percentage is highest in London (8.8%) and lowest in Midlands & East (6.5%).

Ambulance dispatches

One in nine calls to NHS 111 over the winter (11.1%) resulted in an ambulance being dispatched. This percentage peaked at 13.4% on 29th

December, although the raw number of ambulances dispatched peaked on 1st January.

The number of ambulances dispatched was higher at weekends. But since call volumes are also higher, percentage of calls resulting in an ambulance dispatch was lower at weekends than during the week.

The percentage of calls where an ambulance was dispatched was highest in North East England (16.4%) and Devon (16.3%) and lowest in Buckinghamshire (7.5%) and South East London (7.6%). Looking at wider NHS regions, the percentage was highest in the North (11.9%) and lowest in London (9.8%).

Other winter data sources: RCEM Winter Flow report Throughout the winter, the Royal College of Emergency Medicine has published a weekly monitoring report by surveying over 50 health boards and NHS trusts from across the UK. This ran from December to April in 2016/17.

RCEM monitored some data points not discussed here, including:

• Cancelled operations

• Delayed transfers of care

• 4 hour A&E performance (on a weekly basis).

BRIEFING PAPER Number 7057 17 March 2017

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