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

Figures published this week revealed that last winter was the deadliest in more than 30 years.

The statistics, published by the National Records for Scotland, came as the Scottish Government outlined its 'Winter Planning and Resilience' strategy to get health and social care services through the coming winter.

So what do we know so far, and what is the outlook for the months ahead?

Winter deaths

It is normal for mortality to increase between December and March, but what statisticians want to know is whether a particular winter stands out as abnormal.

As far as number of deaths go, 2022/23 was pretty bad: the 24,427 deaths registered was the highest in 33 years (there were 25,497 deaths in the winter of 1989/90). In the five years prior to the pandemic, Scotland had been averaging around 21,200 deaths per winter.

At least some of the uptick in mortality can be blamed on an ageing population who are more vulnerable to winter respiratory infections, falls, and cold weather exacerbating pre-existing heart and lung conditions.

That only goes so far, however. The National Records of Scotland's own data shows that age-standardised mortality rate between January and March this year was 6.2% higher than the five-year average, and 11% higher in December 2022.

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What happened?

This was the first 'normal' winter since the pandemic began. During both 2020/21 and 2021/22, Scotland – and the rest of the UK – spent much of the winter period with restrictions on mixing to suppress first the Alpha, and then the Omicron, Covid variants.

By last winter, social distancing, Covid testing, masks, and self-isolation as a matter of routine had been scrapped. While it was less likely to kill people as a result of immunity built up by vaccinations and prior infections (Covid was the main cause of death in 707 cases last winter compared to 3,532 in the winter of 2020/21), its spread continued to disrupt healthcare services through staff absence, cancelled operations, and bed shortages as disease outbreaks led to ward closures.

Covid mitigations also had the effect of curtailing other viruses, such as flu. In December 2022, Scotland experienced a sudden resurgence of influenza to "extraordinary" levels which in turn led to the highest number of flu deaths in more than 20 years. This partly explains why there were also 1,200 more "respiratory" deaths last winter, such as pneumonia, compared to the previous two winters.

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Scotland's A&E also came under enormous pressure. In the four months from December to March, more than 26,600 patients spent over 12 hours in A&E departments. This was more than double the number of the previous winter (10,900) and by far the highest of any winter, ever, in the history of the NHS.

Nothing provides a clearer signal of the pressure facing the health service: it tells us that beds have run out; that ambulances will be stacking outside unable to offload patients or respond to 999 callouts; and that far too many patients are stranded in hospitals when they no longer need to be there due to shortages of social care and care home availability.

The Herald: Flu rates shown from previous yearsFlu rates shown from previous years (Image: PHS)

This winter?

There are some signs of improvement – the number of people spending over 12 hours in A&E between May and August this year was around 25% lower compared to the same period in 2022 – but delayed discharge rates remain stubbornly high, the number of people in hospital with Covid has been rising since July, and – based on Australia's experience – we probably face another surge in winter flu.

The number of people on waiting lists for treatment has also continued to climb, which means a growing share of the population is in poor health.

The Scottish Government's focus is on initiatives geared to keeping people out of hospital in the first place, with £12 million to expand its Hospital at Home service by 380 beds.

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A further £50m is earmarked for the Scottish Ambulance Service to recruit 317 new frontline staff and 18 extra clinicians for its call centre hub. Again, the priority is trying to prevent admissions – either by paramedics treating more people on the scene, or by medics triaging non-time critical cases into alternative treatment routes.

Is this enough to make an impact?

The take from those on the ground is that this amounts to little more than "tinkering around the edges", and that "little has been done" to change course from last winter's crisis. We'll find out soon enough.