Snowed under? Understanding the effects of winter on the NHS

Nuffield Trust | December 2018 | Snowed under? Understanding the effects of winter on the NHS

A new explainer from the Nuffield Trust unpacks what winter means for the NHS, in terms of its impact on health, demand for services, and how the NHS responds.winter-snow-nature-60561.jpeg

Key points

  • Even moderately cold weather (an average temperature of 5­–8 degrees celsius) results in increased illness and higher death rates.
  • Flu epidemics have a major impact when they occur, but there is significant variation from year to year in how many people and which groups are affected.
  • Primary care deals with most of the increase in winter-related illness. Small changes in the ability of primary care teams to manage peaks in demand become amplified across the wider care system.
  • The number of A&E attendances actually decreases in winter, but the proportion of people admitted increases.
  • A higher proportion of patients with longer lengths of stay in winter means hospitals have less flexibility to manage demand.
  • Given recent trends, we can expect the pressure on the NHS this winter to be similar to last year.
  • Although A&E waiting times tend to grab the headlines, health systems should consider a broader range of factors when assessing winter pressures, from deaths related to cold temperatures and provision of services in the community through to the way acute medical patients are managed in hospital. (Source: Nuffield Trust)


Going Smoke-free: Tees, Esk and Wear Valleys NHS (Mental Health) Trust [Atlas of Shared Learning]

NHS England | December 2018 | Going Smoke-free: Tees, Esk and Wear Valleys NHS (Mental Health) Trust

A nurse led a smoking cessation programme board at Tees, Esk and Wear Valleys NHS Trust implemented a move towards a smoke-free trust, given the demonstrable evidence of the benefits of such an initiative, particularly when recognising the local unwarranted variation of significantly higher numbers of mental health patients at the Trust identified as smokers, compared to the national average.

This led to:

Better outcomes – In a 2016 Friends & Family Test (FFT) 10% of staff who responded identified themselves as smokers. In early 2017 only 8% of staff identified themselves as smokers. Latest FFT data indicated that only 7% of staff identified as smokers in August 2017. The 2018 FFT has completed and the Trust is currently awaiting the final data prior to distribution to staff. Within ‘Trust A’ in the evaluation, the proportion of inpatients for whom smoking status was unknown fell from 39% to 13% over the last 18 months of the study period. There is wider evidence from the clinical audit of smoking status, that smoking prevalence fell within the Trust from 43% in 2015 to 21% in 2018.

Better experience – Both patients and staff have reported that the support provided as a part of the policy has been well-received and a mechanism for change – which is a positive indicator of experience.

Better use of resources – The training and skills provided to staff as part of the initiative have supported them to offer a more holistic approach to care without the need for referral onwards which again will have several benefits to service users and their families. The evidence of the evaluation suggest the monthly cost of prescribing NRT products is not excessive, varying between £3,000 and £4,000 per month within each Trust.

For Trusts looking to go smoke-free, the nurse leadership team at Tees, Esk and Wear Valleys NHS Trust recommend planning at least 12-18 months in advance.

(Source: NHS England)

Read the full case study at NHS England 

Procuring for effective wound management [Shared Atlas of Learning Case Study]

NHS England | November 2018 |Procuring for effective wound management

A case study on the NHS England’s Shared Atlas features an innovation from a nursing team who introduced a centralised procurement system,  generating savings of £45,000 which has been reinvested in services.

The nursing team for the Wound and Lymphedema service at the East London Wound Healing Centre identified significant unwarranted variation in the supply and use of wound care products across their service, with variation in a standardised approach to dressing choice and in some instances the most optimal dressing was not being utilised.


This innovation led to:

Better outcomes – Enabling clinicians to directly order on a patient needs-based approach has improved care and outcomes, helping to identify patients with complex needs and triggering specialist interventions. Standardising wound care based upon best practice will also improve outcomes for patients.

Better experience – The supply system has reduced delays in treatment for patients and keeping track of ordering trends has highlighted training needs and targeted support to some teams and providers. The new system has resulted in effective and efficient access to dressings for patients and improved patient care.

Better use of resources – The scheme has operated within the original budget despite an 18% increase in population. Savings of £45,000 have also been reinvested in services. Total wound care spend per patient in Tower Hamlets is significantly below the national average without compromise on quality of service provision. The procurement system has done this by reducing over-ordering and the associated risk of dressings going unused. The scheme has generated cash savings of £82k that has been reinvested back into services such a wound care projects or interventions.

Read the full case study at NHS England 


‘The gloves are off’ campaign [Shared Atlas of Learning Case Study]

NHS England | December 2018 | ‘The gloves are off’ campaign’

The use of non-sterile gloves has been associated with a significant potential for cross-contamination and transmission of healthcare-associated infections (HAIs). This is because they are often used when they aren’t needed, put on too early, taken off too late or not changed at critical points (Source: NHS England)

A case study recently added to NHS England’s Shared Atlas of Learning, addresses the over-use of non-sterile gloves through education and training. The Lead Nurse for Infection Prevention and Control and two Lead Practice Educators at Great Ormond Street Hospital NHS Foundation Trust (GOSH).


Actions included establishing a working group to develop an educational awareness programme for staff. This included an updated educational package for when gloves should be worn generally in practice and a risk assessment strategy for use of gloves when preparing intravenous medication.

Staff were asked to risk assess when they would wear gloves for giving medication. Gloves were only needed for:

  • any medication where you could be in contact with a bodily fluid. e.g. eye drops, nose drops
  • any therapeutically active cream
  • any liquid hormones or cytotoxic medications.

As a result of the nurses’ actions, the case study reports:

Better outcomes – There has been a reduction in staff attendances to occupational health for hand or skin related problems. The CVL infection rate remains within normal parameters and there has been no adverse rise in hospital acquired infections including Vancomycin-resistant Enterococci (VRE), viral respiratory and enteric infections.

Better experience – The father of a child with learning disabilities gave feedback that his child is hospital and gloves phobic and the project has improved the quality of their life.

The main focus of the project was to provide education and training so that staff felt empowered to risk assess when they used gloves, which has been achieved.

Better use of resources – There has been a significant reduction in the amount of gloves ordered into the hospital. The most recent mean for gloves ordered is 163,125 per week, which is taken from the baseline period between the weeks beginning 15 April 2018 and 29 July 2018, which is a significant reduction on the previous mean of 199,733 units per week a difference of 36,608.

The outcomes of the project are continuing to be monitored and are reported quarterly to staff across the Trust and Nursing Board.

Read the case study at NHS England 

Rough Sleeping Strategy: delivery plan

Ministry of Housing, Communities & Local Government | December 2018 | Rough Sleeping Strategy: delivery plan

In the Rough Sleeping Strategy, published in August 2018, the Ministry of Housing, Communities & Local Government committed to publish a delivery plan setting out how they intend to deliver the 61 commitments they made.


The Rough Sleeping Strategy: delivery plan provides an update on their progress so far, further information including key milestones on all 61 commitments, and information on next steps.

The rough sleeping strategy is a wide ranging document which lays out the government’s plans to help people who are sleeping rough now and to put in place the structures to end rough sleeping for good (Source: The King’s Fund).

Download Rough Sleeping Strategy: delivery plan 

In the news:

BBC News Young homeless blocked from renting, says report

The Guardian 24,000 sleeping rough or on public transport in UK, charity says 

Ways of integrating care that better coordinate services may benefit patients

NIHR | December 2018 | Ways of integrating care that better coordinate services may benefit patients

In one of its latest Signals, the NIHR highlights a systematic review identified 267 pieces of literature from the UK and countries with a comparable economy, all published from 2006onwards, which analysed and described new models of integrated care. 

The review- funded by the NIHR-  looked at the international literature to understand how new care models may affect patients, providers and systems. Almost half of the 267 studies came from the UK. Most investigated integrated care pathways, often as part of a multicomponent intervention including multidisciplinary teams and some form of case management. Most studies focused on older people.



The review finds some positives, but overall highlights the complexity of implementing and assessing new models of care. The reviewers found the complexity and variability of interventions across the literature, a hindrance in understanding the effect of specific changes. Most studies were at risk of bias, with few comparison studies as these are often not appropriate for organisational research (Source: NIHR).

Read the NIHR Signal in full here 

Published abstract here



Domestic abuse victims suffering in silence at work

University of Central Lancashire | December 2018 | Domestic Abuse Victims suffering in silence at work 

University of Central Lancashire (UCLAN) and Sheffield Hallam University researchers have found that victims of domestic abuse working in both the public and private sector generally do not discuss their experiences with their employers. Victims found that in most instances victims of domestic abuse will only disclose this if they are being faced with disciplinary action or sanctions, which are a consequence of the abuse. 


The researchers interviewed trade almost 40 trade union officers from across the north of England about their views on and experience of working with line managers and HR staff who had supported victims of domestic violence.

A key finding of the study is that the workplace is a haven for many victims, financially, physically and emotionally. It also highlights that many managers were still unaware of the signs that their employees are suffering  domestic abuse (Source: UCLAN).


Victimised adolescents more likely to self-harm and have suicidal thoughts

Baldwin, J. R. et al. | 2018| Adolescent Victimization and Self-Injurious Thoughts and Behaviors: A Genetically Sensitive Cohort Study| Journal of the American Academy of Child & Adolescent Psychiatry | Vol.0 |Issue 0| DOI:

Children and young people that are victimised have double the likelihood of self-harm and their risk of suicide  is trebled compared to non-victimised peers according to researchers at King’s College London. The study looked at over 2000 twins born in England and Wales between 1994-95. They studied different forms of adolescent victimisation- including maltreatment, neglect, bullying, crime, sexual victimisation, and family violence- which were identified in interviews with the participants when they turned 18. Among their findings was that over a third of the sample had experienced one severe form of victimisation during their adolescence and 7 per cent had experienced at least three or more severe types of victimisation. Almost 20 per cent (18.9%) had had some form of self-injurious thoughts and behaviours. Victimized adolescents had an increased risk of suicidal ideation and over a quarter had atempted suicide.  




Victimized adolescents have elevated risk of self-injurious thoughts and behaviors. However, poor understanding of causal and non-causal mechanisms underlying this observed risk limits the development of interventions to prevent premature death among adolescents. We tested whether pre-existing family-wide and individual vulnerabilities account for victimized adolescents’ elevated risk of self-injurious thoughts and behaviors.


Participants were 2,232 British children followed from birth to age 18 as part of the Environmental Risk (E-Risk) Longitudinal Twin Study. Adolescent victimization (maltreatment, neglect, sexual victimization, family violence, peer/sibling victimization, cyber-victimization, and crime victimization) was assessed through interviews with participants and co-informant questionnaires at the age 18 assessment. Suicidal ideation, self-harm, and suicide attempt in adolescence were assessed through interviews with participants at age 18.


Victimized adolescents had an increased risk of suicidal ideation, self-harm, and suicide attempt. Co-twin control and propensity-score matching analyses showed that these associations were largely accounted for pre-existing familial and individual vulnerabilities, respectively. Over and above their prior vulnerabilities, victimized adolescents still showed a modest elevation in risk for suicidal ideation.


Risk for self-injurious thoughts and behaviors in victimized adolescents is only partly explained by the experience of victimization. Pre-existing vulnerabilities account for a large proportion of the risk. Therefore, effective interventions to prevent premature death in victimized adolescents should not only target the experience of victimization but also address pre-existing vulnerabilities.

The article is in press but may be requested through interlibrary loan by Rotherham NHS staff 

In the news:

BBC News Teenage victims ‘more likely to self-harm’

(Over)eating out at major UK restaurant chains: observational study of energy content of main meals

Robinson, E., Whitelock, V., Mead, B. R., & Haynes, A. | 2018 | (Over)eating out at major UK restaurant chains: observational study of energy content of main meals|BMJ |363|k4982

Researchers have discovered that meals served in major UK restaurant chains are more calorific than those available in fast food chains. The study published in the BMJ, exmained main meals in 27 food outlets- a combination of 21 restaurants and 6 fast food were sampled.  The research team found that only a small proportion of meals that met public health recommendations for energy content was low. 



Objectives To examine the energy content of main meals served in major UK restaurant chains and compare the energy content of meals in fast food and “full service” restaurant chains.

Design Observational study.

Setting Menu and nutritional information provided by major UK restaurant chains.

Main outcome measures Mean energy content of meals, proportion of meals meeting public health recommendations for energy consumption (less than or equal to 600 kcal), and proportion of meals with excessive energy content (more than or equal to1000 kcal).

Results Main meals from 27 restaurant chains (21 full service; 6 fast food) were sampled. The mean energy content of all eligible restaurant meals (13 396 in total) was 977 (95% confidence interval 973 to 983) kcal. The percentage of all meals that met public health recommendations for energy content was low (9%; n=1226) and smaller than the percentage of meals with an excessive energy content (47%; 6251). Compared with fast food restaurants, full service restaurants offered significantly more excessively calorific main meals, fewer main meals meeting public health recommendations, and on average 268 (103 to 433) kcal more in main meals.

Conclusions The energy content of a large number of main meals in major UK restaurant chains is excessive, and only a minority meet public health recommendations. Although the poor nutritional quality of fast food meals has been well documented, the energy content of full service restaurant meals in the UK tends to be higher and is a cause for concern.

Full article available from the BMJ 

In the news:

BBC News Restaurant dishes ‘contain more calories than fast-food meals’

Review of recent trends in mortality in England

A Review of recent trends in mortality in England | Public Health England

This report summarises the findings from a review of trends in life expectancy and mortality in England. It provides detail on specific population groups and specific causes of death, as well as insight into possible explanations for the trends observed.

The report shows that preventable illnesses, including heart disease and stroke, are one of several factors behind the slowing improvements in life expectancy in England.

The review concluded that a number of other factors, operating simultaneously, have also potentially contributed to the slowdown in life expectancy.

These include:

  • a large increase in deaths in the winters between 2014 and 2018, which was also seen in a number of other European countries – this coincided with the circulation of a subtype of flu, the influenza A (H3N2) subtype, known to predominantly affect older people
  • more older people living with dementia and other long-term conditions, which may make them particularly vulnerable to the effects of flu and other winter risks, and who may be particularly reliant on health and social care services
  • an increase in death rates from accidental poisoning, in particular, drug misuse – this led to mortality rates among younger adults making no contribution to changes in life expectancy trends between 2011 and 2016, in contrast to the small positive contributions seen previously

Full document: A Review of recent trends in mortality in England | Public Health England

Public Health England press release: Preventable illness is factor in slower life expectancy increases