QMR 22 | March 2017

Sicker patients the main reason for A&E winter pressures

Despite the recent media focus on access to GPs, our latest survey of finance directors finds that the rising number of patients with complex health needs is the key factor behind the increasing pressures on A&E departments.

Read the report

In this issue . . .

  • 2017 has not started well for the NHS. More than half of finance directors from the trusts and CCGs we surveyed believe quality of care in their area has deteriorated over the past 12 months.

    Deterioration not due to lack of planning or effort from NHS staff

    However, from our survey it is clear that the deterioration over winter was not due to any lack of effort by NHS providers, commissioners and their staff.


    of trusts surveyed increased their staff to prepare for increased pressure on services during the winter.


    of clinical commissioning groups surveyed paid for extra resources in primary care.

    A wide range of other measures were also used to cope with winter pressures including more step-down facilities, paying higher rates for agency staff or using more outsourcing for elective care. It is sobering to consider what would have happened to performance if the NHS had not pulled out all the stops in an effort to meet increased demand.

    “It is clear that the NHS pulled out all the stops and the pressures on hospitals would have been far worse without extensive planning, the heroic efforts of staff and relatively low levels of norovirus and flu.”

    Richard Murray, Director of Policy

  • 80%

    of NHS finance directors identified higher numbers of patients with severe illnesses and complex health needs as key reasons for A&E pressures.


    of NHS finance directors cited delays in discharging patients from hospital as a reason for increased pressure on A&E.

    Relatively few finance directors identified either poor access to general practice or shortages of clinical staff in A&E as key factors in increased pressure on A&E services.

    Delayed transfers of care, staff morale and bed occupancy rates are main concerns

    Since 2013, A&E performance has been one of the top three concerns for trust finance directors in every QMR but one (and it remains the focus of media reporting). However, its disappearance from the top three now may suggest that finance directors are increasingly concerned about the underlying drivers of poor performance rather than the standard itself.

    Longstanding pressures affect performance

    This winter, flu and norovirus have not put a significantly greater demand on health services than in previous years, nor has it been a particularly cold winter.

    Rather, sustained increases in demand over many years, rising delayed transfers of care and seven years of low growth in NHS and social care spending have taken their toll.

  • Finance directors say that they are very unlikely to meet either the A&E four-hour or 18-week referral-to-treatment waiting time standards by the end of this financial year (2016/17). This will be the first year since it was introduced that the elective waiting time standard has not been met for a whole year.

    “Recent media attention has focused on A&E departments and funding of social care, with rather less attention on patients waiting to begin elective care.”

    James Thompson, Senior Research Analyst

    Trusts and CCGs remain pessimistic about future finances

    Looking ahead, 53 per cent of trusts and 63 per cent of CCGs are fairly or very pessimistic about reaching financial balance in 2017/18. For CCGs, this has doubled from 30 per cent who were fairly or very pessimistic when they predicted their financial position for 2016/17 this time last year, underlining the spread of financial distress into the commissioning sector.

    These financial pressures mean some trusts are planning to reduce their workforce.


    of finance directors report that their organisations have plans to reduce permanent clinical headcount.

    However, it will be very challenging to reduce the clinical workforce at a time when many NHS hospitals are routinely running at high bed occupancy levels and demand continues to rise. It is not surprising that staff morale remains a key concern for finance directors.