This article appears as part of the Inside the NHS newsletter.

Winter is the toughest time for the NHS. Cold weather drives people indoors, creating optimum conditions for respiratory viruses to spread.

Icy roads and pavements mean more slips, trips, and broken bones.

Sickness absence among staff goes up exactly when hospital occupancy is at its highest, leaving A&E departments gridlocked and ambulances stacking outside.

For many hospitals, this is a year-round occurrence - but it is still at its worst in winter.

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How bad was 2023/24?

According to the latest report from the National Records of Scotland, there were 1,796 excess deaths in December 2023 to March 2024 compared to the non-winter periods either side. 

In total, there were 21,983 deaths registered - 10% fewer than the previous winter, which had been the deadliest in 30 years.

Winter is associated with higher mortality levels (Image: NRS) A quick look at A&E statistics suggests that capacity was most stretched during the first week of January since this was the only time all winter that performance against the four-hour target dipped below 60%.

In that week alone, 2,260 people spent over 12 hours in A&E (for comparison, just 146 patients did so during the first week of January in 2019).

Health boards are getting used to a new normal.

In its winter planning documents published ahead of its board meeting on October 29, NHS Greater Glasgow and Clyde (NHSGGC) noted that recent winters "have had a larger impact on mortuary services than at the height of the Covid-19 pandemic with indications that this will be the new norm".

It added: "We will ensure the provision of some additional mortuary capacity to deliver the increased requirements during winter 24/25."

as hospital occupancy goes up during winter, A&E departments tend to become more gridlocked as patients wait for beds to become free (Image: DerekMcArthur/Newsquest)

Winter planning

Budget pressures are making it more difficult than ever for health boards to create the 'surge capacity' - that is, extra beds - needed to cope with winter.

In its board papers, NHS Lothian notes that "financial limitations" are "making it impossible to action additional interim care beds in the system" to get more patients out of hospital when ready, and "impossible to action additional NHS capacity" to keep planned procedures going as demand from unscheduled care goes up.

In NHS GGC - Scotland's largest health board - the winter preparedness plan proposes opening an extra 48 beds for use between January and March 2025.

This alone will eat up a "significant proportion" of the £2.58m allocated to its winter plan.

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Some existing initiatives are helping to free up beds.

The OPAT service - whereby patients requiring intravenous antibiotics can be treated as outpatients - is freeing up some 50 beds a week, and GGC is looking to expand this into its Clyde and North divisions.

Yet this sits against the "circa 300 people delayed on any given day over the last 20 months" and the 135 care homes in GGC region under "significant pressures, with occupancy levels exceeding 95%".

Nonetheless, the Scottish Government - which has repeatedly promised to drive down waiting lists - has asked health boards to prioritise the protection of planned care this winter so that fewer operations are cancelled.

GGC says it will "focus on increasing the separation of elective and unscheduled care"

A certain number of beds will be set aside at Glasgow Royal Infirmary, Gartnavel General and the Victoria Ambulatory Care hospital "to support elective activity over the winter period" for orthopaedics and general surgery.

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At the Queen Elizabeth University Hospital, beds "will be protected to allow urgent, complex and cancer patients to be treated and ensure planned care beds are not utilised for boarders" - that is, patients being relocated from other areas of the hospital.

Meanwhile, some plastic surgery beds at Glasgow Royal Infirmary will be set aside for urgent cancer surgeries (75% of the plastic surgery elective programme is for breast and skin cancers) and the Institute for Neurological Sciences will ring-fence beds for spinal surgery in patients with lower back pain - many of whom have been waiting over a year.

The trade-off is that A&E departments may find themselves even more crowded than usual, which brings its own risks.

There are no win-wins in winter for the NHS.