Update on winter planning and delivery

Agenda item: 5 (public session)
Report by: Sarah-Jane Marsh, National Director for Integrated Urgent and Emergency Care and Deputy Chief Operating Officer
Paper type: For discussion
1 February 2024

Organisation objective

  • NHS Mandate from Government

Executive summary

Significant progress has been made despite a challenging context. To date, urgent and emergency care (UEC) performance has been better than last year in every month since the UEC Recovery Plan was published, despite higher demand.

Industrial action by junior doctors placed another period of pressure on UEC in December and January. A significant amount of work and resource was invested to prepare for and manage the industrial action periods, particularly since it coincided with the usual winter pressures seen by the NHS in January.

Action required

The Board is asked to note the information provided in the report.


1. In January 2023, a Delivery Plan for recovering urgent and emergency care services was published with two key targets for delivery over 2023/24:

  • Patients being seen more quickly in emergency departments: with the ambition to improve to 76% of patients being admitted, transferred or discharged within four hours by March 2024, with further improvement in 2024/25.
  • Ambulances getting to patients quicker: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25.

2. In preparation for winter, integrated care boards (ICBs) were asked to develop system-level resilience and surge planning, to avoid becoming overwhelmed at times of peak demand. As part of building this resilience, ICB’s were asked to re-assure capacity expansion plans, including the national commitments for 5,000 additional core general and acute beds, and 10,000 new virtual ward ‘beds’ as well as additional ambulances on the road. Systems were also asked to focus on progressing the high impact improvement interventions set out in the UEC Recovery Plan.

3. There has been consistent improvement in emergency performance this year, with performance significantly better every month since the UEC Recovery Plan was published than the year before. This is despite significant challenges including more than 40 days of industrial action, with more than £1bn associated cost, and ongoing disruption from covid.


4. The pressure on the integrated urgent and emergency care pathway has remained high over winter. In December 2023, there were 2,179,232 attendances in A&Es across England, an average of 70,298 per day. Between April and December 2023 there were 5.5% more emergency admissions than the same period last year. Despite this, the proportion of patients attending A&E who were admitted, transferred or discharged within four hours remained above last year, at 69.4% compared to 65% in December 2022.

5. Ambulance services answered 889,389 calls to 999, or 28,690 per day in December 2023, which was 4.2% more than November. Ambulance services also handled 760,589 incidents. 380,793 of incidents were conveyed to A&E, which equates to 12,284 per day during December. The average response time for a category 2 call in December 2023 was 45 minutes and 57 seconds. This is half the average time in the same month last year, which was 1 hour, 32 minutes and 55 seconds.

Capacity expansion and progress on high impact initiatives

6. A key component of winter resilience is stepping up capacity and improving ways of working in hospital’s and in the community. The NHS has delivered on its target of 5,000 additional general and acute core beds, so that more than 99,500 core beds are open across the country by January 2024. This has been supported in part by the investment of £250m over 2023/24 in capital schemes to deliver additional capacity.

7. Even with financial pressures from industrial action, NHS England has worked with ambulance trusts to grow ambulance crews on the road, leading to more Category 2 incidents responded to this winter compared to last December (receiving an ambulance 47 minutes faster than in December 2022). We already have more than 300 new double crewed ambulances on the road, and further deliveries including mental health response vehicles planned over 2023/24 and 2024/25.

8. Throughout December 2023, improved handovers between ambulances and hospitals meant a 38% reduction in hours lost from handovers taking longer than 30 minutes compared to the previous year, freeing up capacity for ambulances to respond. Ambulance trusts have also implemented demand management protocols to ensure ambulances are prioritised for responding to the sickest patients.

9. The NHS has also built its resilience by treating more people in the community and in the best place to meet their needs:

  • In December, 11,805 virtual ward beds were delivered, a growth of 141% since May 2022, over-achieving against the original target.
  • The standard for responding to 70% of urgent community incidents in 2 hours has been exceeded consistently, with current performance at 85% and 20,000 more referrals in the most recent data than the same month last year (September).
  • All NHS areas have developed a Care Transfer Hub, to support complex discharges. All hubs have been encouraged to meet the domains of best practice set out in the Intermediate Care Framework, to ensure patients with complex needs are discharged in a timely way with appropriate assessment and onward care. In December, the NHS discharged 10,300 patients, a 12.5% growth since the same period last year.

10. A new discharge ready date metric was published in November. Around 50% of providers are already reporting acceptable data. This will support understanding of how to improve flow and discharge processes and we are working with providers to ensure all Trusts are reporting high quality data.

Support for systems

11. To support systems to deliver the progress described above, all systems over August to December 2023 had access to a universal support offer delivered by NHS England. The offer focused on 10 high-impact, evidence-based, and clinically supported interventions across the integrated UEC pathway. All 10 modules were accredited by the Faculty of Medical Leadership and Management.

12. Additional operational oversight and support has been deployed to the most challenged systems over winter. This is supported by a new and improved Operational Pressures Escalation Levels (OPEL) Framework, that enables escalation conversations to happen on a consistent evidence basis across the country and across local, regional and national levels.

13. Bespoke and intensive support has been provided to organisations in the tiering programme which includes a tailor-made improvement approach depending on the changes identified. This has continued throughout the year and is focused on the most challenged geographical areas. Tier 1 systems are showing improvement in performance because of the tiering approach and are receiving the highest level of support to help them achieve their ambitions.

14. Tiering involves a system-wide review of the current support and data and includes conversations with the integrated care system, providers and region, tools from the Emergency Care Improvement Support Team and Getting It Right First Time, and wider national and regional improvement resources. We have learnt from phase 1 of tiering that each system will have differing challenges and opportunities, and therefore it is important to create a solution that is fit for purpose and this will be further evolved going forwards.

Next steps

15. In the week commencing 22 January NHS England wrote to systems to reinforce delivery of winter plans:

  • Ensuring all elements of capacity in plans are implemented, including:
  • Reinforcing daily grip and oversight of plan delivery, including through building on the existing escalation arrangements to avoid excessive ED and ambulance handover times.
  • Ensuring patients don’t come into hospital who don’t need to be there by:
  1. Utilising ARI hubs/primary care to manage moderate illness/disease
  2. Utilising Virtual Wards as step-up care and step down
  3. Increasing senior decision making at the front door
  4. improving discharges by increasing senior presence on wards
  • Ensuring best practice operations of the emergency department itself, including ensuring streaming and redirection and use of UTCs is maximised to reinstate high performance in non-admitted streams.

16. NHS England will continue to regularly review and monitor delivery of the headline ambitions set out in the UEC Recovery Plan, the input metrics to deliver the plan and operational pressures, and continue to work in a bespoke way with individual sites, trusts, and systems to help maintain improvement and address specific pressures where they arise.