The planning is over and winter has begun

21 December 2018

Iyoni Ranasinghe, Consultant

Although winter officially starts today, anyone involved in the health service will have been planning for months to deal with expected pressures. Last winter was particularly challenging for the NHS. The then Health Secretary described it as the “worst ever” and NHS England Chief Executive Simon Stevens called it the “most pressurised month the NHS has seen in its nearly 70-year history”. Unprecedented demand resulted from the worst flu outbreak seen this decade, compounded by the cancellation of all January’s planned operations and overflowing A&E departments and ambulance services.

Nevertheless, patients continued to receive safe care in this period due to the continued dedicated efforts of frontline staff. Over 90 in 100 patients were admitted, transferred or discharged from A&E within four hours. This was possible because of the planning efforts made in advance, including Quality Improvement (QI). Last winter could have been worse without such measures. Winters are always going to a difficult period for healthcare with an ageing population, however. The system remains under pressure and the next few months will show what we have learned from the experience of last year and how QI can help.

QI is defined by the US Institute of Medicine as “….the degree to which health services for individuals and populations increase the likelihood of desired health outcomes…”. As a result, QI can be used to increase capacity and ensure we reduce variation across the system. The Institute of Medicine identifies six dimensions of healthcare quality, known as STEEEP.


Healthcare leaders need to consider the STEEEP principles in planning for winter pressures. Looking at the pressures of last year, one area where resilience needs to be developed further is in ensuring there is enough capacity to meet pressures. In 2017, East London NHS Foundation Trust used QI methodology to support with reducing length of stay and bed occupancy on an older adult psychiatric ward. In 12 months, length of stay was reduced from an average of 47 days to an average of 30 days, and bed occupancy reduced from 77% to 54%. The ability for the NHS to free-up beds this year will be a key quality and performance determinant.

A reduction in best practice variation will also support reducing patient delays. Whilst healthcare will always have variation, the key question is whether the variation is normal for the process (common cause variation) or an unpredictable deviation (special cause variation e.g. the Australian flu outbreak last year). It is vital we understand and reduce variation in patient populations by monitoring outcome and process measures using QI methodology. This will help us better plan for winter demands and use resources more efficiently.

Additionally, in 2016, North East London NHS Foundation Trust (NELFT) aimed to improve staff experience through engagement in QI. This NELFT Quality Improvement Programme (NQIP) had an impact on both staff retention and empowerment, with one staff member saying: “Involvement in QI has helped me understand better the nature of change and has allowed me a greater understanding of my job role as clinical lead.”

There are many examples across the NHS of how even small-scale QI initiatives can lead to significant benefits for patients, staff and carers, as well as deliver better value. If QI techniques are applied consistently and systematically, the potential to deliver is even greater. This is not currently the case, however. If the NHS intends to deliver sustainable and improved care, it needs to move from isolated examples of innovation and good practice to system-wide improvement. QI will involve substantial shifts in our idea of healthcare work which is vital to reduce the winter pressures seen every year.

The foundation of QI is the bottom-up combined and unceasing effort of everyone – patients, carers, staff – to make the changes necessary to improve outcomes for all, as well as improving system performance. The rapid small-cycle tests of change and the learning from failure approach behind QI accelerates progress. Applying QI as part of winter planning will enable, not only healthcare leaders, but all involved in healthcare to analyse their local situation and pressure points, as well as implement effective processes which will improve the safety, efficiency and effectiveness of the system as well as help manage major obstacles.


  1. STEEEP Principles as outlined in the IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century
  2. NELFT Quality Improvement Programme:
  3. ELFT Reducing Length of Stay and Bed Occupancy:
  4. Winter 2017/2018: