According to the health secretary, the NHS is at “one minute to midnight” and Christmas strikes could be the “Jenga piece that collapses the tower”. Last year the head of NHS England, Amanda Pritchard, warned of “unprecedented demand”; the year before that, Wes Streeting, then in opposition, warned the NHS was facing what could be its “worst winter crisis”. Three winters ago was, according to the BMJ, going to be the “worst winter on record”.
Proclaiming pain for the NHS has become an annual ritual. But, internationally speaking, is this normal? Do other countries suffer winter crises every year?
Britain’s health service is not unusual in dealing with tough underlying conditions at this time of year. Deaths in winter months tend to be a fifth higher than in non-winter months in most European countries. This winter will take the same shape, although higher death rates may arrive sooner than expected. The highly infectious H3N2 “subclade K” influenza strain — similar to the variant that gave Australia one of its worst flu seasons in recent memory — is adding pressure to already strained healthcare systems.
Hospital admissions for flu in England are higher than they usually are at this time of year. But France is said to be à bout — at breaking point — as it grapples with the double impact of flu and a doctors’ strike. In Spain camillas en los pasillos (stretchers in corridors) have become common, and patients in Madrid are waiting up to three days to be admitted to hospital. Wards in Germany are being shut because of Rekord-Krankenstand (record sick leave).
Pressure in emergency departments, particularly in winter, is not unique to Britain. The standard of Britain’s A&E service has fallen since the pandemic. Ten years ago 91 per cent of visitors were seen within four hours; today it is 74 per cent. Yet in the US a recent study of “boarders” — patients stuck in A&E waiting for inpatient beds — found that the proportion of patients waiting less than four hours fell as low as 60 per cent in winter 2022.
Staff shortages, a smorgasbord of bugs and a shortage of care home beds have created seasonal bottlenecks the world over. But in one crucial measure Britain has made life harder for itself.
Hospitals need unused capacity to function properly. Spare beds make it easier to move people between wards and begin treatment. When bed occupancy passes 90 per cent, shortages become common, inefficiencies creep in and the risk of infections rises. NHS guidance says occupancy should not exceed 92 per cent. Last week it barely dipped below 95 per cent. On December 5 four hospital trusts had no spare beds at the time of the daily count.
Occupancy levels are similar every winter, it is easy to forget how absurd this seems from the viewpoint of other countries. Throughout 2023 England averaged 90 per cent occupancy, and Scotland 88 per cent, both having increased in the past two decades. The equivalent figures were 74 per cent in France, 72 per cent in Germany and just 62 per cent in the Czech Republic, according to Eurostat.
In Britain, says Siva Anandaciva of the King’s Fund think tank, having lots of spare capacity can be seen as not making full use of your assets, which could be used, for example, to bring down waiting lists. Running a healthcare system “red hot” all year round may seem insane to the rest of Europe but is deemed productive here.
The approach has consequences. A 2021 paper found that the risk of hospital-acquired infections — an indicator of overcrowding — was more than twice as high in English hospitals as German ones. Moreover, NHS studies have identified a clear statistical link between rising bed occupancy and long A&E waiting times. Research by the Royal College of Emergency Medicine found that 16,644 excess deaths in 2024 were linked to A&E stays of 12 hours or longer. A decade ago the annual number of patients waiting more than 12 hours in A&E was about 1,400; in the past year 557,000 patients have had to wait that long in emergency departments.
Britain has one of the lowest rates of hospital beds per capita in the OECD, a problem that nobody (outside half-baked election promises to build 40 hospitals) has made a serious attempt to remedy. While other countries fear bad winters, Britain should know to expect them. When pressure can be blamed on harmful flu variants or low vaccine uptake, the crisis is at least temporary. When it is driven by chronic shortages of beds and staff to run them, it is permanent. Until politicians confront that difference, Britain will keep treating structural failure as a seasonal surprise.