Winter crisis

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While this article is biased towards the situation in the UK it describes a phenomena common to all emergency health care provision

A feature of most health systems is a Winter crisis where emergency healthcare demand exceeds resources available in secondary care. While perceived as therefore a secondary care problem, increasingly it is recognised as primarily being caused by poor whole systems design, management and resourcing. Indeed the epidemiology of winter excessive mortality reveals that interventions such as improving housing stock and winter heating are extremely important[1]. Typically this may be manifest by excessive waits for treatment in Accident & Emergency departments, usually around the Christmas holiday break. The importance of holidays is emphasised by similar Easter crisis in Christian societies. Often political or cultural will does not exist to design out of the system the root causes of such crisis. Indeed it is likely political based redesign will create unintended consequences or predictable consequences such as impact on workforce morale.

LogoKeyPointsBox.png Excessive winter mortality can be improved at the macro level by[1]:
  • Improved protection from the cold indoors
  • Increased public spending on health care
  • More equitable income distribution

It is not significantly associated with:

  • The number of hospital beds (per 1000 population)
  • The number of GPs (per 1000 population)

Both the public and healthcare staff can be very confused over the cause of such crises. They are not inevitable if the health and social care system has been well designed, resourced and managed. Most winter demand is very predictable as are the consequences of not having sufficient bed capacity. Bed capacity can be misunderstood as it is often seen as a flow of patient into and out of a classical reservoir of beds rather than a quantum reservoir problem. Indeed the multiple outlet pathways also create quantum issues which manifest chaos theory effects, the fewer patients who follow a pathway. It is even possible to design for a influenza outbreak, although a completely new illness such as SARS is much more problematical. They are not simply caused by excessive demand, as it is possible to have predictable demand causing a crisis due to inadequate bed base and discharge efficiency. For example in the absence of an unpredicted major infection outbreak in the winter of the English NHS had a winter crisis due to inadequate secondary care bed base and inadequate community care resources[2]. The most effective way of preventing such "winter crisis" for any given configuration of whole system care is to ensure that all significant care pools are resourced for a responsive occupancy defined by predictable demand. This usually fails to be created because of these factors:

  1. Poor management
    • Ultimately in a system as complicated as the NHS and subject to political whim with the law of unintended consequences this is usually at Government level. Local crises due to poor management are able to be coped with if good whole systems management has planned for the bad/corrupt and fraudulent creating local inefficiencies
    • Poor understanding of relevant information
      • Some have progressed little from Hippocrates observation that mortality is higher in cooler than in warmer months[3]. The illnesses presenting at greater frequency in winter are not just infections and the increase of about a third in population mortality is not just due to them which has implications for resource planning[4]. It has long been known that myocardial infarction[5] and stroke have apparently significantly increased incidence in Winter (by about a third) although much of this is artifact due to coding, diagnostic failings and greater morbidity due to say complicating infection or the actual associations with external temperature and stress events[6]. Morbidity increases seasonally so there is a greater institutionalisation rate in winter[7].
      • Planning is unlikely to assume that norovirus in the community closes care home beds to admission and stops care staff from caring for a patient load as no-one talks to occupational health about care worker seasonal sickness rates or correlates data of sickness impact
      • Perceived as an input problem. This is because the full A&E/emergency room is easy to ascertain and count, while the failure to train and employ enough staff for peak demand for convalescence at home is harder to quantify
      • It is known that a discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition[8]
    • Investment decisions
      • For example underinvestment by a government in social care will create a winter crisis
      • Cost of capacity only used for a few weeks of the year has opportunity costs elsewhere
      • Manpower planning
        • For example underinvestment in nurse training
        • Contracts that allow annual leave at times of peak activity
        • Workforce burnout/retirement not being allowed for
    • Inadequate design
      • Appropriate reward for the system roles necessary.
        • For example if disincentives exist to undertaking the extra activity necessary in a winter crisis it does not happen. In the NHS in England extra activity can have a tariff disincentive or community beds were subsidised but without adequate notice to build and recruit to the subsidised capacity. Opening of empty wards that did exist was heavily discouraged.
        • Care package staff paid more for not taking leave at Christmas
  2. The financial cost
    • Overtime and other payments
    • Capacity in one part of the system to deal with the winter crisis precipitated by carers leave at Christmas could be unused for most of rest of year if for example training programs were not planned around periods of low demand
    • Health care system expenditure in those over 65 years old appears to increase by a third in Winter compared to summer[7]
  3. The investment time scale
    • This is usually 5 to 10 years due to time taken to train/redeploy manpower and build new plant or infrastructure
  4. System design
    • Factors such as school holidays, European working time directive, failure to promote and develop responsive care at home, training curriculum inadequacy, work force characteristics, job demarcation, poor communication


  1. a b Healy JD. Excess winter mortality in Europe: a cross country analysis identifying key risk factors. Journal of epidemiology and community health. Oct; 57(10):784-789.(Link to article – subscription may be required.)
  2. The A&E winter crisis: lessons from last year Nuffield foundation December
  3. Chadwick J, Mann WN, Lloyd GER Hippocratic writings. London, England: Penguin Books. (1983) 380 p
  4. Kalkstein AJ. Regional similarities in seasonal mortality across the United States: an examination of 28 metropolitan statistical areas. PloS one. ; 8(5):e63971.(Link to article – subscription may be required.)
  5. Kloner RA, Poole WK, Perritt RL. When throughout the year is coronary death most likely to occur? A 12-year population-based analysis of more than 220 000 cases. Circulation. 1999 Oct; 100(15):1630-1634.(Link to article – subscription may be required.)
  6. Rothwell PM, Wroe SJ, Slattery J, Warlow CP. Is stroke incidence related to season or temperature? The Oxfordshire Community Stroke Project. Lancet (London, England). 1996 Apr; 347(9006):934-936.(Link to article – subscription may be required.)
  7. a b Rolden HJ, Rohling JH, van Bodegom D, Westendorp RG. Seasonal Variation in Mortality, Medical Care Expenditure and Institutionalization in Older People: Evidence from a Dutch Cohort of Older Health Insurance Clients. PloS one; 10(11):e0143154.(Electronic-eCollection) (Link to article – subscription may be required.)
  8. Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. The Cochrane database of systematic reviews; 1:CD000313.(Epub) (Link to article – subscription may be required.)