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Patients and staff queue outside an NHS emergency department at night during snowfall, with ambulances lined up and people waiting to enter the hospital.

Crisis

Santa slumped into his Howard & Sons armchair … a present to himself… next to the roaring, log-fire.

Snowflake, one of the Elves, helped him ease off his boots and poured him a glass of Penderyn.

‘That’s it for another year’ said Santa, ‘we’ll take a couple of days off and then we’ll have to start planning for next year.’

… and that’s how it’s done. Organising the most compressed logistics and production challenges on a global scale.

As well as being an icon of good cheer, generosity and Ho, ho, ho… Santa is undoubtedly a student of Mintzberg’s 5 Ps for Strategy… planning, getting organised and getting stuff done.

Unlike the NHS where, if not Christmas, certainly winter, always seems to come as a surprise… at least that’s what the press and people in phone-ins would have you believe…

… of course it’s not true. Winter planning started back in June.

Nevertheless, it is one of the most persistent questions put to the NHS every year; why didn’t it prepare for winter?

The premise is wrong.

The NHS prepares for winter every single year. What it can’t do is what Santa can do… rely on fairy dust and magic, to conjure up some help… in the NHS there’s no magic that can create capacity…

… that no longer exists.

NHS winter planning is neither casual nor last-minute. Systems and hospitals produce formal plans months in advance.

Extra funding is allocated, elective work is scaled back to create headroom, escalation beds are opened, discharge schemes are accelerated, virtual-wards expanded and often, staff leave curtailed.

Flu and COVID vaccination programmes are targeted. That’s preparation, on a grand scale.

The problem is…

… winter planning is being asked to compensate for a structural weakness built into the system…

… England runs with far fewer hospital beds than comparable systems.

The UK has around 2.5 hospital beds per 1,000 population. Across much of Western Europe and the OECD, the figure is typically between four and eight. Germany; eight beds per 1,000, France around six, Italy three and a half.

These countries go into winter with slack in the system. We don’t…

… the NHS operates permanently close to full. Safe hospital occupancy is usually considered to be around 83%. In England, hospitals routinely run at 90-95% … before winter has even started.

When seasonal illness arrives… flu, RSV, COVID, norovirus, cold-related admissions, demand doesn’t stretch the system, it overwhelms it.

Every winter… emergency departments back-up because wards cannot take patients. Ambulances queue outside hospitals because EDs are full. Elective care is cancelled because surgical beds are given over to medical patients.

Staff are forced into constant crisis-management, not because they failed to plan, but because there is no buffer left to absorb pressure.

Social care compounds the problem. Winter pressure is as much about flow-out as flow-in.

Thousands of hospital beds are occupied by people medically fit for discharge who cannot leave because the social care capacity they need doesn’t exist.

This is not an NHS failure… it is the consequence of a fragile care market competing for staff with worse pay, conditions and stability.

You cannot discharge patients into care that isn’t there, no matter how good the plan looks on paper.

The myth that the NHS ‘fails to prepare for winter’ persists because it is politically convenient.

It reframes a long-term policy choice… running the system hot, with minimal spare capacity… as a short-term management failure.

Over the past 35yrs, the total number of NHS hospital beds has more than halved… 1987 nearly 300,000 beds… by 2019, falling to around 140,000.

Over that period, population (England) has grown from about 47.3m to around 56.6m by 2020… it is now accelerating driven by births, ageing and migration.

Numpty politicians, egged on by think-tanks, are beguiled by the sunny uplands of shorter bed-stays, improved technologies, virtual wards… all fine until winter comes.

Planning can mitigate pressure, but it can’t substitute for beds, staff and social care capacity that have been systematically stripped out.

Until that reality is acknowledged, winter will continue to arrive on schedule…

… and so will the annual crisis.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.

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