NHS England Status Update: Dec 2023
An overview of key NHS England hospital metrics for December 2023 covering emergency care.
Introduction
A deep-dive into some of the key performance metrics published each month by NHS England (NHSE). It is best viewed using your browser or the Substack app.
December 2022 saw some of the worst ever NHS performance levels for Ambulance and Accident & Emergency (A&E) services in England. Whist the performance in December 2023 was much better than last year for Ambulance services it was not for A&E. This post explores some of the reasons for the improved performance and highlights the large gap that remains with prior years.
Summary
The performance of the Emergency Services significantly worsened in 2022 leading to record highs for ambulance response times and A&E waiting times in December 2022.
The double burden of the Winter 2022 Flu and Covid waves was the main factor that pushed the already fragile Emergency Services to their poorest ever performance.
This winter there have been far smaller Flu and Covid waves resulting in less beds occupied by patients suffering from these illnesses and lower staff absences.
The December 2023 ambulance response times improved and are about half the levels seen in December 2022, even though the number of incidents attended by was higher. However, they are still over twice as high as the historic levels and NHSE targets.
Unfortunately, A&E performance metrics for December 2023 tell a different story. Performance levels have hardly improved from 2022 and are still far worse than a few years ago despite attendance levels decreasing.
A year of Worsening Performance.
December 2022 had some of the worst ever levels of performance for ambulance and A&E services in England but this did not come without warning. Performances had been getting progressively worse since mid-2021.
The following chart shows the average monthly ambulance response times in minutes for urgent (C2) incidents from April 2018 to Dec 2022. The national target is to reach these incidents, which are typically for strokes and chest pains, within 18 minutes.
Up until May 2021, response times were around 20 minutes but then started to increase significantly and by 2022 the average response time had more than doubled to around 50 minutes. Also the month to month variability was much greater in 2022 which is a sure sign that a system is under pressure and increasingly fragile.
The next chart shows a similar picture for so called ‘Trolley Waits’. These are the number of patients waiting longer than 12 hours in A&E from the decision that they should be admitted until they are admitted to hospital.
Once again, before May 2021 there were a very small number of patients waiting longer than 12 hours but since then there has been a significant increase and by December 2022 over 54,000 patients waited over 12 hours to be admitted!
These two charts are typical of other performance metrics for the ambulance and A&E services. They show the increasing fragility of these services from May 2021 onwards and how ill-prepared the Emergency Services were for the shocks that were about to hit in December 2022.
The Emergency Services in Crisis
The major shock that came in December 2022 was a very rapid increase in the prevalence rate of Flu at the same time as higher Covid rates were also rising. This had two impacts on hospitals. First, admissions and beds occupied by Flu and Covid patients increased rapidly. This slowed the patent flow through A&E which resulted in the extremely high levels of ‘Trolley Waits’ and ambulances being used to hold patients which stopped them responding to incidents. The second impact was that more NHS staff were off sick which reduced the capacity to treat patients.
Finally, December 2022 did see industrial action in the NHS with ambulance workers striking on December 21st and some nurses striking from December 15th and 20th. This must also have had some impact on emergency care but it’s difficult to quantify as performance was worsening ahead of the strikes.
How Do the Pressures in Winter 2023 Compare?
In the previous section we saw that in December 2022 the fragile ambulance and A&E services were hit by a very rapid increase in the prevalence rate of Flu at the same time as Covid rates were also rising. These increases resulted in large numbers of beds occupied by patients with Flu and Covid and high levels of staff sickness.
How does December 2023 compare?
Let’s start by comparing the number of adult General and Acute (G&A) beds occupied by Flu patients with December 2022.
The chart shows that about a third fewer beds are occupied by Flu patients this December and we have not seen the rapid rise we saw last year. For reference, the peak number of beds occupied by flu patients in December 2022 was 5,779 out of just under 100,000 G&A beds available.
The next chart compares the number of adult G&A beds occupied by Covid patients.
For both years the number of beds occupied by Covid patients is much higher than for Flu, but we can see that far fewer adult G&A beds are occupied by Covid patients this year and the rise has been less steep.
Just to put this in to perspective, in December 2022 the highest percentage of adult G&A beds occupied by Flu and Covid patients was 15.3% of all available G&A beds, whereas the highest in December 2023 was 5.5%. This means that many more beds were available for other patients in December 2023.
As well as the beds being occupied by Flu and Covid patients, the number of beds occupied by patients remaining in hospital waiting to be discharged needs to be considered. The following chart gives a yearly comparison of those patients occupying hospital beds who no longer meet the criteria to reside.
The chart shows that fewer beds are occupied by patients who are eligible to be discharged. In December 2023 there were 1,500 fewer which again means more beds were available to treat patients.
The second impact of the high prevalence of Flu and Covid was on NHS staff absences, and the next chart compares the overall number of absences by year.
The peak level of staff absences in December 2022 was 81,800 which is an absentee rate of about 6.3%. This year the number of staff absent reduced to 68,000 this year which is about 5.2% of staff. The chart shows that about half of the reduction came from the lower number of absences due to Covid.
In summary, this winter the pressures from Flu and Covid on hospital beds and staff are much less than last year.
Ambulance Performance in December 2023
The following dashboard summarises the metrics showing demand for ambulance services in England. To recap, C1 incidents are those that are life threatening, C2 require urgent attention (heart attacks and strokes), and C3 / C4 are less serious incidents.
In December, the average daily number of incidents attended by ambulance (21,949) was 3% higher that the demand seen in the prior month. The mix of incidents attended also changed compared to November as there more 7% more life threatening C1 incidents and 4% more serious C2 incidents with 3% less C3 incidents.
In comparison to December 2023 there were 9% more incidents attended this month. However, there were 13% fewer of the most serious life threatening C1 incidents although the number of incidents for the other categories was higher. This should mean that there was less of a burden on A&E resources this year arising from life threatening incidents.
The following table shows the ambulance response times for the all categories of incidents for England.
Ambulance response times for all categories were higher than last month and continue to exceed target response times for life threatening (C1) and urgent (C2) incidents. However, ambulance response times were significantly lower than last year which had record high response times.
The following chart compares the ambulance response times for urgent incidents (for example, strokes and chest pain) for December 2023 with 2022 and 2019
This December the average response time for urgent incidents was about half (46 minutes) the response time for December 2022 ( 93 minutes) but this was still much higher than December 2019. Although performance has improved it is still a long way from the levels we had a few years ago or the 18 minute target.
Accident and Emergency Performance in December 2023
An important measure of Accident and Emergency (A&E) performance is the excess time it takes for ambulances to hand patients over to the A&E department. This is because it occurs as a result of a mismatch between A&E/hospital capacity and the number of emergency patients arriving.
National guidance states that patients arriving at an emergency department by ambulance must be handed over to the care of A&E staff within 15 minutes. The following chart shows the average ‘excess’ time, above the 15 minutes target, lost per ambulance handover by month and year.
There was a slight increase in the time lost per ambulance handover in December 2023 compare to December. Although exceeding target, this month was significantly lower than in December 2022 and should indicate that A&E is performing much better than last years record poor. However, we will see later that is not the case.
Turning now to A&E performance. The next chart is a yearly comparison of daily attendances at A&E departments and covers both major A&E departments and minor injury units.
A&E attendances in December 2023 were 70,300 per day which was lower than the 74,000 attending per day in 2022 and very close to those attending in December 2019.
The next chart shows a yearly comparison of the percentage of people admitted, transferred, or discharged within four hours from their arrival in A&E. This is for people waiting in acute hospital trusts who have the most serious need. The long-standing target is for this percentage to be above 95% but this was last achieved in August 2014! The NHS Winter Plan interim target is to get above 76% by March 2024.
In December 2023, only 55% of people attending A&E in acute hospital trusts were seen before four hours from arrival to admission, transfer or discharge. This is slightly lower than November and the third worst performance ever. The performance is a far lower than the historic trend and a long way from the March 2024 ‘Interim Target’ of 76%.
The next chart shows a yearly comparison of the number of so called ‘trolley waits’ where patients wait longer than 12 hours in A&E from when the admission decision was made to the time they were admitted to a hospital ward.
In December 2023, the number of ‘trolley waits’ was 44 ,045 which was the third highest number number ever and way higher than the historic trend.
In Conclusion
Whilst the winter pressures from Covid and Flu are much less in 2023 than in 2022 the December performance levels for the Emergency Services in England show a mixed picture.
Ambulance performance metrics are much better in December 2023 than last year with lower lead times and more incidents attended. Despite these improvements the performance remains worse than a few years ago and well above target levels.
A&E performance metrics for December 2023 tell a different story. Performance levels have hardly improved from 2022 and are still far worse than a few years ago.