- The system came into the winter with long-standing capacity issues. This winter then saw average bed occupancy comparable to 2019/20, at 6.6 per cent higher than 2021/22 and 21.1 per cent higher than in 2020/21; which put pressure on the NHS’s low physical bed capacity.
- This was exacerbated by difficulty discharging to the community and care sector. On an average day, 13,469 beds were taken up by patients who no longer needed to be in hospital, an increase on an already challenging 2021/22 where the number was 11,661.
- Hospital flow concerns at the back door meant pressure at the front door. 28.9 per cent of ambulances across the winter were delayed by over half an hour (21.6 per cent and 10.7 per cent in the previous two winters. The highest pre-pandemic week was 18.1 per cent in 2019/20.)
- This winter also saw the challenges of flu and COVID-19 together, with an average of over 7,000 beds taken up by people with COVID-19 on an average day in January, and nearly 3,000 with flu.
- And those problems, combined with industrial action, long-term workforce issues including 133,000 vacancies and high leaver rates mean that while winter pressures have historically been challenging for the NHS, this winter had added new pressures.
- As we go into summer with baseline performance well below usual, we can see that without further action to address long-term challenges the recent trend of poorer performance looks set to continue.
NHS England’s Urgent and Emergency Care Daily Situation Report collects daily returns from acute trusts and includes data on bed occupancy, ambulance handover delays, delayed discharges and staff absences. The data highlights where there are pressures across the healthcare system throughout the winter period. This article provides a round-up of the 2022/23 situation report (sitrep) data and compares to previous years in order to put recent figures into perspective and look into why performance may have been different.
The following analysis will primarily report on weekly averages rather than absolute totals in winter due to differences in reporting periods for the sitrep, which started two weeks earlier in 2022/23 than the previous year, which was in turn earlier than the year before. There are also some differences in available metrics affecting the ability to do some comparisons, or differences in how reporting was split (i.e. adult and paediatric beds versus overall).
Bed occupancy in urgent and emergency care services
Occupancy rate for general and acute beds was consistently higher in this past winter compared to the previous two winters. On average per week, general and acute bed occupancy was 94.1 per cent across the 2022/23 winter. This compared to 91.6 per cent across 2021/22 and 85.9 per cent across 2020/21. No weeks saw occupancy above 94 per cent in both the previous two winter periods in comparison to 2022/23, which highlights the considerable differences in week-on-week pressures.
Yet occupancy was broadly comparable to pre-pandemic, an indicator that bed occupancy alone may not be the only reason for performance challenges this winter, even if the occupancy levels are above what many consider safe and emphasise the risk of the low number of beds the NHS has compared to its international peers.
Occupancy rate is a function of total beds occupied divided by total beds available. On average, there were 94,685 beds occupied per week (95.7 per cent occupancy rate) in 2022/23 which was 6.6 per cent higher than 2021/22 (88,795) and 21.1 per cent higher when compared to 2020/21 (78,176).
It is important to note that there were moderately more beds available in hospitals in winter 2022/23 than in the previous two years, and slightly more than in 2019/20.
The recent quarterly KH03 return shows that total beds (including general and acute, learning disabilities, maternity and mental illness) available overnight on an average day was 129,957 in Q3 of 2022/23, and 130,863 in Q4. This compares to 128,326 and 128,943 in the respective quarters of 2019/20.
Within this, 2,349 more general and acute beds in Q4 of 2022/23 than pre-pandemic. In contrast, during the pandemic, as a result of infection prevention and other COVID-19-related interventions, over 8,000 beds less general and acute beds were available in Q4 2020/21. The chart below also shows the comparable data we have in the winter sitrep using type 1 trusts (with major A&E departments) for which data is available:
Despite a small increase in beds available this winter, the NHS has seen many beds occupied by patients who had been in hospital for a long period of time, at least a little more so than that pre-pandemic winter:
On average per week, there were 48,706 beds occupied with patients staying in hospital up to seven days – 11 per cent higher than in the winter of 2021/22 (43,960); 37 per cent higher than the first pandemic winter (35,606); 13 per cent higher than in 2019/20 (43,226).
The trend continues for 14 and 21-day stays and a core reason is the issues around discharging patients.
One of the challenges driving high bed occupancy is the difficulty discharging patients. The chart below shows the number of patients who experienced these delays:
Across 2022/23, there were 13,469 patients who were medically fit to be discharged but were delayed, on average per week. This was 16 per cent more than the total number of patients who faced delays with discharge in the previous winter – where there were 11,661 in comparison. There are several capacity-related reasons for this, with an important one being the lack of social care provision with an estimated 165,000 job vacancies at the last count.
Comparable data is not available for 2019/20, with the now discontinued delayed transfers of care replaced by the no criteria to reside metric used above. That return showed a rising trend up to February 2020, and feedback from our members suggest things have got considerably worse even since then.
Other factors affecting occupancy
The challenges of a more severe flu season also affect comparisons to the previous winter, and affected occupancy. The chart below shows the surge in beds occupied by flu patients, which peaked in the Christmas period with over 5,000 patients in hospital beds. To put it in perspective, throughout the entirety of 2021/22 winter period there were a total of 875 beds occupied by flu patients – so a single Christmas week in 2022/23 saw a sixfold increase in the demand for beds compared to the entire winter period in the previous year. This is perhaps unsurprising, as non-pharmaceutical interventions for COVID-19 meant much lower levels of flu circulating in the two winters.
Completely equivalent flu data is not available going back pre-pandemic, as it was not part of the sitrep. However, with measures that can be compared winter to winter, UK Health Security Agency (UKHSA) National flu and COVID-19 surveillance reports show that in 2022/23, weekly overall ICU admission rates rose higher than any of the previous five years had reached (at the turn of the year, matching the high overall occupancy of beds by flu patients shown above). However, in 2017/18 and 2018/19 in particular, the impact continued for longer than after the peak than this winter.
In addition to flu, the NHS had to respond to pressures due to increases in patients with respiratory viruses and diarrhoea and vomiting. On average, there were 565 beds closed off due to patients with diarrhoea and vomiting/norovirus-like symptoms, compared to the weekly average of 278 in 2021/22, over 100 per cent difference.
We can also see that this was a larger problem in the winter of 2022/23 than it was in 2019/20:
Similarly, there were higher number of paediatric beds closed due to respiratory syncytial virus (RSV). For instance, there were 56 beds closed off on average per week across 2022/23 winter period, more than four times higher when compared to 2021/22 (11 beds closed on average per week).
Increased handover delays are a symptom of wider patient flow issues, something we have looked at previously. Data for this winter includes the number of hours delayed as well as the volume of delays for the first time. The difference in proportion of handover delays across England is shown in the chart below.
The proportion of ambulances delayed when handing over patients started from a considerably worse point this winter than it had been previously and rose significantly leading up to and during the Christmas period where it peaked to 43.7 per cent, meaning more than two out of five ambulance arrivals had been delayed at least by 30 minutes. Handover delays are clearly linked to response times; if ambulances are waiting outside emergency departments then they cannot be responding to incidents in the community.
On average, 28.1 per cent of all ambulance arrivals were delayed in 2022/23 compared to 21.6 per cent in 2021/22 and 10.7 per cent in the winter prior to that. Interesting to note however is that the volume of ambulance arrivals was greater in both 2020/21 and 2021/22 where there were 11,929 and 12,713, ambulance arrivals per week on average, respectively, compared to 10,952 in 2022/23.
Ambulance demand then, cannot be the core reason for increased levels of handover delays. Above we have talked about the effects of patient flow with both occupancy and discharge challenges; these undoubtedly play a part. We have also heard about regional variation, culture and dedicated handover teams. Examples of trusts with low proportions of handover delays are included in the Association of Ambulance Chief Executives’ latest data report on national ambulance data.
Industrial action and long-term workforce issues were compounded by absences. The chart below shows average number of absences for 2022/23 and 2021/22. Staff absences prior to 2021/22 are not publicly available in the same format.
On average per week, there were an average of 57,597 absences reported for 2022/23 winter period. This was considerably lower however when compared to the previous winter period where 91,131 weekly staff absences were reported – approximately 60 per cent lower.
Yet digging into the separate, monthly sickness absence rates, we can see that in December 2022, the sickness absence rate was 6.28 per cent. This is comparable to last winter (6.21 per cent in December 2021) but significantly higher than pre-pandemic winters: December 2019 saw 4.86 per cent of staff absent, while December 2018 saw 4.51 per cent. Read NHS England absence rates data for more detail.
The data reveals that the 2022/23 winter period was considerably more challenging for some of the standard performance measures and operational pressures in the winter sitrep, particularly compared to the previous two years where COVID-19 preparation and treatment was a considerable burden.
This was a return to a more pre-pandemic type winter. However, the NHS now carries the scars of a pandemic, which created a shock to our lean health service, the effective running of which relies on few disruptions and free patient flow.
Recovery from this position will be difficult over the coming years. Exacerbated hospital flow issues means patients are waiting at both front and back doors of the service, and we continue to see other disruptions including a challenging peak of flu and workforce issues - higher vacancies, staff absence and rising staff discontent as evidenced by both industrial action and the NHS staff survey. We await the workforce plan and accompanying investment to support long-term solutions here, as well for further discussions to solve the ongoing industrial action.
And while our members have responded to these broad challenges and many metrics have improved since the peak of winter, the data lays bare the long-term problems facing the service. This is not just related to workforce but includes lack of bed stock meaning the service is often running to close or full capacity and the problems discharging patients in part due to the lack of capacity in social care, which in turn impacts hospital flow.
This article aims to summarise what has happened in winter 2022/23 but also to provide context into the potential knock-on effect of a challenging winter on recovery as well as offering a better understanding as to what happened last winter.
How is the NHS performing?
View our analysis of all of the latest NHS performance figures for a rounded view of how healthcare services are coping under immense pressure.