Winter Pressures Report Executive Summary
Feedback from NHS Boards
This Executive Summary should be read in conjunction with the additional paper
‘Examples of Good Practice’ available at the National Winter Planning Meeting, June 2009
BACKGROUND
1.
In March 2009 the Scottish Government Emergency Access Delivery Team
commissioned a report to review the pressures experienced by NHS Scotland during the winter
of 2008/2009.
2.
We have seen a significant improvement in the 4 hour A&E waiting times in recent years,
increasing from 87% in June 2006 to delivery of the current 98% 4 hour HEAT standard.
However, there was a drop in performance in 11 out of the 14 territorial Health Boards against
the 4 hour standard in December 2008 and January 2009. The overall performance for NHS
Scotland during these months dipped below 98% (96.7% and 96.5% respectively). Additionally,
there had been media interest in how well the NHS had handled winter in parts of Scotland,
particularly in the central belt, with stories about trolley waits, and hospitals not coping with the
impact of adverse weather conditions. Figures for March 2009 show performance improved to
97.7% with a 140,000 attendances (compared to 128,084 in December).
3.
The review was carried out by Dr. Daniel Beckett, Acting Consultant at the Royal
Infirmary of Edinburgh, with support from NSS Information Services Department (ISD) and
Scottish Government Analytical Services Directorate (ASD). Each NHS Board in Scotland was
visited, plus the relevant Special Boards, to obtain a wide range of professional and staff
perceptions about their local experience of winter using semi-structured one-to-one interviews.
Quantitative data and information was provided by ISD and ASD.
4.
The report focussed upon December and January as these were the months that correlated
with the poorest performance against the 4 hour target. Comparison was made with previous
winter performances, particularly 2006/2007 (as 2007/2008 was widely considered to have been
atypical)
KEY FINDINGS
5.
The key findings from the qualitative and quantitative aspects of this report are
summarised below
Hospital Admissions
6.
There was a general perception amongst some Health Boards that winter 2008/2009 had
been ‘busier than previous years’ in terms of total numbers of admissions, and that the peak had
commenced earlier. Health Boards commented that the age profile of patients admitted over
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winter appeared to be older, with more patients suffering from respiratory disease resulting in
greater lengths of stay.
Data from the SMR01 dataset confirmed that, compared with the five year monthly mean, there
was a 7.9% increase in all emergency admissions across the NHS in Scotland in December 2008,
followed by a 1.8% increase in January 2009 (graph 1). Furthermore there was an 11% increase
in the number of patients admitted to hospital with respiratory illness over December and
January compared with winter 2006/2007.
However there was no evidence for a
disproportionate increase in admission of elderly patients, or greater lengths of stay.
Hospital Discharges
7.
Low levels of hospital discharges, particularly over the festive period, was highlighted by
almost every NHS Board as a challenge over winter 2008/2009.
8.
Graph 2 shows total hospital admissions and discharges and four hour breaches over
December and January. What can clearly be seen is a stable admission/discharge profile in
December, with peaks of admissions at the start of the week, mirrored by a peak of discharges
towards the end of the week. Admissions outnumbered discharges every weekend and generally
on Monday. There was a large surge of discharges on Christmas Eve followed by an eleven day
holiday period. On nine of these eleven days admissions outnumbered discharges. The net
effect of this was that hospitals were at high levels of bed occupancy when the elective
programme restarted at full capacity on 5th January, evidenced by a spike in four hour breaches.
The system attempted to return to a stable admission/discharge profile over the following week,
but had not recovered by the following Monday, 12th January, and a further spike in four hour
breaches was noted.
9.
Reasons highlighted by professionals and staff for this reduction in discharges over the
festive periods included:
 lack of consultant staff in downstream wards
 lack of discharge infrastructure over the festive period (e.g. Patient Transport
Services, Allied Health Professionals and social work); and
 a perceived lack of coordination of decision making in the system over the festive
period
10.
Tools for discharge planning, such as Estimated Date of Discharge (EDD), and Nurse
Led Discharge (NLD) were used patchily, and in some Boards not at all.
11.
Boards reported almost universal improvement in numbers of delayed discharges, with
NHS Scotland achieving zero delayed discharges over 6 weeks by April 2008 and 2009. A small
number of Boards continued to be challenged by significant numbers of delayed discharges
under 6 weeks which had a negative impact on the ability of systems to cope over the winter
period.
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Capacity and Demand Planning
12.
Nine out of the fourteen territorial Health Boards have developed an internal tool to
predict unscheduled activity, and these were largely found to be accurate. Two Boards employed
tools to predict discharges based on previous discharge patterns. Despite Boards being
encouraged to use System Watch, there was little use for medium to long term predictions of
activity despite its proven accuracy. Graph 3 shows the Systemwatch prediction for winter
2008/2009. Activity started to increase early (2nd November), but then short term prediction
followed well after 2-3 weeks
13.
Eight out of eleven mainland Boards opened additional capacity beds in their acute sites
this winter. Many Health Boards had difficulties accessing the full complement of community
beds, despite the acute site being near, or over-capacity. These difficulties included:
 lack of Patient Transport Services
 complex referral pathways
 patient choice
Escalation Plans
14.
There was significant variation between Boards in the effectiveness of local escalation
plans. Most Boards had a bed management escalation plan, but the triggers for escalation varied
between predicted activity, actual observed activity, or simply perception of activity. There were
reports of managers and clinicians (including primary care) becoming desensitised to red alert.
Conversely there were some reports of middle management being reluctant to escalate, or senior
mangers refusing to escalate to red alert.
15.
CHP involvement in escalation plans was variable, with one example of an escalation
plan being developed by CHP senior management. However CHP middle managers were not
fully sighted on this and were unable to respond when necessary.
Elective Activity
16.
Eight of the fourteen territorial Health Boards continued with elective work until
Christmas Eve and also between Christmas and New Year, whereas six Boards ran a ‘cancer and
urgent only’ service over the festive period. The decrease in elective admissions on 29th
December (60% of a ‘normal’ Monday) is shown on graph 2.
17.
The perception in several Health Board areas was that since the introduction of the 18
week Referral to Treatment Target, and the disbanding of the Unscheduled Care Collaborative,
the 4 hour standard may have been de-prioritised. Examples of this included:
 surgical wards (with staff available) remaining closed over the festive period despite
eight hour, or greater, trolley waits in the Emergency Department
 waiting list initiatives on 5th January despite clear predictions of high levels of
unscheduled medical activity
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18.
Over this winter seven Health Boards did not cancel any elective procedures due to lack
of beds, five cancelled a small number (<15 each) and two cancelled significantly more.
Staffing
19.
Three major challenges regarding staffing over winter were highlighted:
 in some areas there could be a problem with non-clinical staff retention in out of
hours GP services because staff on Agenda for Change were not paid unsociable
hours over the festive periods. However, this was not noted to be a problem for nonclinical staff employed by NHS24 under Agenda for Change
 implementation of MMC and nationalised medical recruitment has led to many
medical posts, particularly within Emergency Medicine, remaining unfilled.
 a perception of lack of social work availability due to significant amounts of annual
leave being taken over the festive periods
Boarding (outliers)
20.
Each of Scotland’s eleven mainland Health Boards used boarding of patients outwith
their own speciality beds as a solution to capacity issues. Over winter in some sites up to 20% of
all medical patients were boarders, occupying more than 10% of the total bed complement.
There had been a recent move to board patients from the Admission Unit (and in exceptional
circumstances the Emergency Department) before initial consultant review. This potentially
introduced a layer of clinical risk and could be considered an issue of clinical governance.
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Recommendations

Health Boards should ensure that their winter planning starts early and that the
process includes Community Health Partnerships and Social Work Departments.
There should be a clear relationship between the winter plan and pandemic flu plan.

Integral to the winter plan should be the escalation plan. This should involve all
stakeholders including Community Health Partnerships. This includes the utilisation
of beds in Community Hospitals, and protocols for referral should be agreed now,
dealing with any challenges regarding perceived bed ownership

Systemwatch should be used systematically for long to medium term predictions of
unscheduled activity, and those predictions should be acted upon to create the
required capacity, both in terms of beds and to support initiatives to avoid admission.
Consideration should also be given to the use of Systemwatch for planning of elective
activity over the winter months.

The level of discharges over the holiday period should be improved. This might
include:
o increased consultant presence with dedicated discharge ward rounds in
downstream wards
o utilisation of a rapid response team (or equivalent) of AHPs with access to
homecare packages without recourse to social work assessment
o re-energising and establishing ownership of the Estimated Date of Discharge
policy, plus introducing Nurse Led Discharges (NLDs)

Boards should undertake more accurate modelling over the festive period to plan
elective capacity and optimise the use of bed capacity. This may then enable
hospitals to reduce the number of elective admissions on the first Monday in January.
Further consideration should be given to front loading the first week in January with
minor procedures, and back loading with majors. Also medical elective activity (such
as clinics and endoscopy lists) could be back loaded during this week.

If all the above measures have been undertaken, including consultant review and
discharge of downstream patients, and all capacity beds filled (including community
beds); priority should be given to emergency admissions over routine elective
procedures. The Scottish Government has, for the last 10 years, made it clear that
clinical decision making always trumps targets.

Boards should work towards eliminating the boarding of patients as a solution to bed
capacity problems. Specifically, the boarding of patients from the Admissions Unit
and/or Emergency Department should never occur.
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Appendix A. Likert scale results
Each interviewee was asked to answer five simple questions with their answers being recorded in
the form of a Likert scale. The questions were as follows:
Question 1
The local health system coped well with winter pressures this year
1
2
3
4
5
Disagree
Neutral
Question 2
Areas of increased demand were accurately predicted
1
2
3
4
Disagree
Neutral
5
6
7
Agree
6
7
Agree
Question 3
The board’s winter plan prepared the local health system for the increased pressure
1
2
3
4
5
6
Disagree
Neutral
7
Agree
Question 4
If there were times that the system struggled to cope, was this due to factors within the NHS
board (primary/secondary care) or external agencies (. NHS24/local authority services/Scottish
Ambulance Service)?
1
2
3
4
5
6
7
External
Combination
Internal
Question 5
If there were times that the system struggled to cope was this due to predictable or unpredictable
factors, or a combination?
1
2
3
4
5
6
7
Predictable
Combination
Unpredictable
Interviewees were broadly grouped into one of three categories
 Hospital management
 Secondary care clinicians
 Representatives of GP out of hours services (both clinical and non-clinical)
Clinicians (total)
Clinicians (A&E)
Management
GPOOH
Question 1
4.6
3.9
5.3
5.7
Question 2
5.0
4.9
5.5
4.7
Question 3
4.5
4.1
5.3
5.0
6
Question 4
3.9
4.0
4.3
3.4
Question 5
3.4
2.8
3.7
4.4
Appendix B. Graphs
Graph 1. Scotland emergency and elective inpatient admissions
winter 0809
2000
1800
1600
1400
1200
1000
800
600
400
200
3rd
1s
t
De
c
De
5th c
De
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De
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De
c
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th
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c
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th
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rd
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25
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st
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2n
dJ
an
4th
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n
6th
Ja
8th n
Ja
n
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th
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12 an
th
Ja
n
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nd
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28 an
th
Ja
n
30
th
Ja
n
0
Emergency admissions
5-year-monthly-average
Elective admissions
Source: SMR01 linked catalogue updated 2nd May 2009
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5-year-monthly-average
Graph 2. Scotland level hospital admissions and discharges
with A&E breaches from CORE sites - Dec08-Jan09
3500
3000
2500
2000
1500
1000
500
3rd
1s
t
De
c
De
c
5th
De
c
7th
De
9th c
De
c
11
th
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13
th
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th
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th
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th
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rd
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th
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st
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2n
dJ
an
4th
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n
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Ja
n
8th
Ja
n
10
th
Jan
12
th
Jan
14
th
Jan
16
th
Jan
18
th
Jan
20
th
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nd
Jan
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Jan
26
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28
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30
th
Jan
0
Number of Inpatient Admissions
Number of Inpatient Discharges
Source: SMR01 linked catalog updated 2nd May 2009
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Number of 4 hour breaches
Graph 3. Systemwatch prediction vs actual activity August 2008-August 2009
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