Start now to get our patients winter-ready

It may be depressing to be thinking about winter in the middle of summer, but there is no better time to start preparing our patients with long term conditions to reduce their risk of seasonal illnesses and help relieve NHS winter pressures

I recently chaired a conference which had the theme of uplifting outcomes for people living with chronic obstructive pulmonary disease (COPD). The focus was on improving quality of life through optimising symptom management and reducing the risk of exacerbations but there was much discussion about improving patient education, offering group consultations and how we could improve communication between primary and secondary care. It crossed my mind that we should be implementing these ideas as soon as possible because investment in people living with long-term conditions now is likely to have longer-term benefits for all. It may seem a little depressing to think about winter in the middle of summer but in fact there’s no better time. With winter pressures on the NHS being at an all-time high (pandemics excepted), it is essential that the public and healthcare professionals consider what should be done to prepare people for winter in order to relieve some of those pressures. Through greater awareness of contributing factors to winter pressures, thought can be given to reducing the risk of winter illnesses and optimising the management of long-term conditions in order to reduce unplanned admissions.

WHAT CONTRIBUTES TO WINTER PRESSURES?

According to an analysis by the Health Foundation, last winter saw record attendances at emergency departments (EDs) with waiting times reaching a record high, particularly in those having to wait 12 hours or more before admission.¹ Only 73% of A&E patients were treated within 4 hours, well below the target of 95%.Ambulance handover times were significantly delayed and were worse than over previous winters. However, the focus should not be solely on these statistics: we need to go further upstream to understand why people are going to ED in the first place. One reason given is that people are simply unable to get appointments at their general practice, but those of us working in general practice know that we are working harder than ever and are offering extended hours in an attempt to meet demand. So, could it be that people are simply sicker in the winter?When the data were studied at the end of last winter, it was clear that two key illnesses had led to this unprecedented demand: flu and diarrhoeal illness.

Hospital admissions for flu were similar to previous years but took longer to fall, as people stayed in hospital instead of going home. This resulted in a 50% higher number of bed days taken up by people with flu, mainly due to delayed discharges.Bed occupancy has risen consistently over the past 15 years, suggesting that the service is at bursting point. Interestingly, hospital admissions for respiratory syncytial virus remained steady, while admissions for COVID-19 were low.¹

Considering that flu is a viral illness, I had to ask my secondary care colleagues why people with flu might be admitted. I was unclear as to what hospital care might offer beyond self-management at home. I was told that admission is based on how sick the individual is, what the risk of sepsis might be and what their National Early Warning Score (NEWS)-2 score is.² They may require anti-viral treatments, antibiotics for secondary infections, intravenous fluids or even critical care. The NICE Clinical Knowledge Summaries on treating flu say that admission is likely to be needed for people with ‘complicated influenza’, defined as where there are signs and symptoms that require hospital admission, the presence of a lower respiratory tract infection (hypoxaemia, dyspnoea, and lung infiltrate), central nervous system involvement or significant exacerbation of an underlying medical condition.³

The other issue is that people with long-term conditions who contract flu are at increased risk of further health problems. If someone has COPD, for example, a flu infection might lead to an acute exacerbation. Acute exacerbations of COPD (AECOPD) are associated with an increased risk of future exacerbations and further loss of lung function.⁴ Additionally, AECOPD have been shown to increase the risk of cardiovascular events and heart failure with a concomitant rise in morbidity and mortality.⁵

Nonetheless, the authors of the Health Foundation report took the view that while conditions were challenging last winter, they were similar to previous years and not, in fact, greatly in excess of what the health service should normally expect. They go on to say that blaming winter illnesses for the high level of attendances at EDs and hospitals actually fails to recognise the real issue, which they say is the low resilience of the NHS.¹ If the ‘winter crisis’ happens every year, is it really a crisis or a failure of service planning?

WHAT CAN PRIMARY CARE DO?

Arguably, it is through preparing people for winter that the demand for secondary care services might be controlled. If flu is one of the biggest causes of admissions and use of bed days, more needs to be done to prevent it. It is greatly disturbing, then, to study the statistics for the numbers of people accessing flu vaccinations, particularly those who are at greatest risk of contracting flu. The latest figures available show that only 41.4% of the at-risk groups age 6 months to 65 years were vaccinated and that only 77.8% of the over 65s had their flu vaccination.⁶ This is well below the level of 95% which is required for herd immunity, and which will protect the tiny number of people who truly cannot have any of the vaccines available.

Not only that, but only 37.9% of healthcare workers (HCWs) had their flu jab in 2024/5.⁷ Any HCW who is infected with the flu virus will be asymptomatic for the first few days of their infection so will be at work, seeing vulnerable patients and potentially passing the virus on. It is deeply worrying (and indeed, mystifying) why HCWs of all people are failing to protect themselves and others. Achieving better coverage in at-risk groups must be a priority for HCWs, both in terms of explaining to people why the vaccination is so important but also with respect to getting their own vaccination to protect those at risk.

OPTIMISING THE MANAGEMENT OF LTCs

Asthma

People with long-term conditions (LTCs) can be proactively prepared for winter in order to reduce the impact of their LTC on their general wellbeing and to minimise the risk of them needing an unplanned admission. The recent changes to the BTS/SIGN/NICE guidelines for asthma, with the focus on anti-inflammatory reliever (AIR) therapy and maintenance and reliever therapy (MART), should help to reduce the rate of exacerbations and, by extrapolation, hospital admissions. It is essential, then, that everyone is aware of the guidelines and in particular the fact that anyone on an AIR or MART regime should not be using a blue short-acting bronchodilator.Asthma + Lung UK have information on these approaches which can be shared with patients, available at https://www.asthmaandlung.org.uk/symptoms-tests-treatments/treatments/air and https://www.asthmaandlung.org.uk/symptoms-tests-treatments/treatments/mart, respectively. Using an inhaled corticosteroid/formoterol combination inhaler instead of a short-acting B2 agonist has been shown to improve outcomes such as symptom control and exacerbation risk.8 Self-management is in-built with AIR and MART but all people living with asthma should have a written self-management plan and Asthma + Lung UK have examples which can be personalised to the individual, available at https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/AAPs/completing-asthma-action-plan-your-patients .

Chronic obstructive pulmonary disease

In people living with COPD, the NICE guidelines9 remind clinicians of the importance of smoking cessation, pulmonary rehabilitation, and vaccinations as the foundation of COPD care.Inhaled therapies such as dual bronchodilators and triple therapies can improve symptoms and exacerbation risk with some triple therapies showing a possible mortality benefit too.10 At the recent COPD conference, some people described how they had increased attendance at PR by simply saying ‘would you like to see the physiotherapist about your breathing?’ as an introduction to what PR could offer. People may not know what PR is (or like the sound of it) but people are more likely to understand the role of the respiratory physiotherapist and, perhaps, sign up for the programme as a result. PR programmes will also support with mental health and with lifestyle changes such as better nutrition and smoking cessation. NICE recently updated its guidance on smoking cessation and encourages the use of dual nicotine replacement therapy, varenicline and cytisine to help people to quit.11Again, Asthma and Lung UK have lots of resources to help people living with COPD to understand more about their condition and to self-manage with confidence, available at https://www.asthmaandlung.org.uk/conditions/copd-chronic-obstructive-pulmonary-disease.

Diabetes

Any infection can cause a deterioration in diabetes control, so avoidance of preventable infections is an important part of managing diabetes holistically.Appropriately tight control of risk factors, including glycaemic management, blood pressure (BP) and lipids should underpin the risk-reduction strategy for people with diabetes. However, the increased focus on the use of SGLT2 inhibitors for glycaemic control and cardiorenal protection along with metformin and ACE inhibitors will also require people living with diabetes to understand how and when to implement the sick day rules in order to reduce the risk of diabetic ketoacidosis (DKA). The sick day rules can be summarised using the term ‘SADMAN’ – reminding people to temporarily postpone the use of SGLT2 inhibitors, ACE inhibitors, Diuretics, Metformin, Angiotensin receptor blockers and Non-steroidal anti-inflammatory drugs (NSAIDs) during a period of acute illness. There are two risks to future health here – the risk of DKA and also the risk that people will forget to restart these medications (with the exception of NSAIDs) once they are well again.Ensuring effective management of cardiovascular risk factors along with avoidance of acute illness through the use of vaccinations, good hand hygiene and where necessary, the use of masks in public places, can all help to reduce risk. Diabetes UK has a wealth of information for the public and for HCWs on the management of diabetes, at https://www.diabetes.org.uk/for-professionals/supporting-your-patients .

Cardiovascular disease

Diabetes is a cardiovascular disease (CVD) and many people with diabetes will suffer complications related to CVD in the future. Many infections result in an inflammatory state and as CVD is an inflammatory condition, the impact of an infection can add insult to injury.¹² This was observed during the pandemic when the pro-inflammatory, pro-thrombotic coronavirus caused a significantly increased risk of dying in people living with obesity, CVD or diabetes – all inflammatory conditions. Statins have been shown to have an anti-inflammatory effect, and anti-platelets can reduce the risk of thromboembolic events, so once more it is vital that medication is optimised, the importance of adherence is stressed, and vaccination and infection-avoidance advice is clear and unequivocal. Heart UK and the British Heart Foundation can support people living with these conditions – See Resources.

Atrial fibrillation (AF) is associated with an increased risk of CVD and heart failure. People with AF (which may be asymptomatic) are at significantly increased risk of a stroke and those strokes are more severe than non-AF-related strokes.¹³ Infections, particularly sepsis, can increase the risk of AF so once again, avoidance of infections is key.¹⁴ However, the importance of detecting AF through regular pulse checks (teaching people to do their own is key), carrying out an ECG if the rate and/or rhythm is abnormal and reducing stroke risk through the use of anticoagulation, where indicated, cannot be over-emphasised. Adherence to anticoagulation medication is essential and this is arguably easier when taking a direct oral anticoagulant than with warfarin. However, regular monitoring of INR levels can help those who need to be on warfarin, especially in times of potential disruption such as when on antibiotics. Arrythmia Alliance and the Stroke Association can be relied upon for advice and support regarding these conditions.

Heart failure is often the end-result of other conditions which increase the risk of this diagnosis, including COPD, diabetes, atrial fibrillation and cardiovascular disease. Decompensated (acute) heart failure is, once again, associated with infections, such as flu, pneumonia and COVID.¹⁵ There may be a sense of déjà vu here, but once again, infection prevention is key.The four pillars of the management of heart failure with reduced ejection fraction – ACE inhibitors/ARBs/ARB +neprilysin inhibitor plus beta blocker plus spironolactone or eplerenone plus dapagliflozin or empagliflozin – are known to offer best outcomes in terms of symptoms and in terms of mortality. An audit can identify gaps in current management and ensure people are suitably protected for the future, irrespective of the weather or the time of year.Self-management through adjustment of diuretics can also help and resources such as Pumping Marvellous can help to support people to understand more about mastering their condition. People with heart failure with preserved ejection fraction will benefit from being on dapagliflozin or empagliflozin, and again, an audit can identify those who might be missing out.

Children and pregnant women

Infections can spread like wildfire in schools and nurseries.For that reason, great care should be taken to reduce the risk, through basic hygiene procedures. Children and pregnant women are also considered to be at increased risk of flu and are more likely to suffer devastating consequences. They are therefore advised to have a flu jab. Obviously if they also have a long-term condition such as asthma or diabetes, that risk will be even greater. The role of HCWs in primary care should be to be clear about the risks of flu and the benefits of the vaccination.

MANAGING THE WORKLOAD

Primary care is taking on more and more work, some of which was, in the past, carried out by secondary care. The care we deliver is more complex and takes more time. Flu clinics are often arranged to ensure as many people as possible are seen at the start of the vaccination season in order to reduce the risk of a flu epidemic.However, now could be a good time to think about seeing people with LTCs to educate them about their condition and about the importance of being ‘winter-ready’. Exacerbations of respiratory conditions such as asthma often start to increase around September time so there is little point to waiting until then to advise people about how to reduce their risk. It is worth considering offering group education sessions (different from group consultations) to ensure people are aware of what excellence in long-term condition management looks like, as briefly described in the examples given above. The Health and Wellbeing team and other local support organisations could be invited in to offer their input. For some people, the main issue with winter pressures is getting their shopping in or staying warm.This proactive approach is time-effective but also shows people that we are concerned about their wellbeing and want to help them stay as well as possible. Group consultations, where individual annual reviews are carried out with everyone else listening in, can be extremely effective for peer support and optimising the management of LTCs more efficiently.

IN SUMMARY

Getting winter-ready in order to reduce morbidity and mortality, but also to minimise the impact on an over-stretched NHS, is everyone’s responsibility.Clinicians need to support people to engage in healthy behaviours, and infection control procedures should be followed by HCWs and public alike. Long term condition management should be optimised through lifestyle changes and pharmacological interventions, and everyone should be vaccinated against flu and other infections unless such vaccinations are contraindicated.This will be the exception, rather than the rule. It truly is of enormous concern that a simple vaccination, which is what it is for most people, is being overlooked or even refused by those most likely to benefit from it – and not just in terms of avoiding being poorly for a week.The consequences of a case of flu in someone who is at high risk can be fatal. It is vital that HCWs are perfectly clear about the risk of infections, specifically flu, and are unequivocal about the importance of having the vaccination and ensuring that their condition is managed as well as possible to reduce the risk of significant harm. For unvaccinated HCWs, the harm is not just to themselves but also to others.

RESOURCES

• Association of Respiratory Nurses https://arns.co.uk/
• Asthma + Lung UK https://www.asthmaandlung.org.uk/
• Arrythmia Alliance https://heartrhythmalliance.org/aa/uk/
• British Heart Foundation https://www.bhf.org.uk/
• Diabetes UK https://www.diabetes.org.uk/
• Heart UK https://www.heartuk.org.uk/
• Primary Care Cardiovascular Society https://pccsuk.org/
• Primary Care Diabetes and Obesity Society https://www.pcdosociety.org/
• Primary Care Respiratory Society https://www.pcrs-uk.org/
• Pumping Marvellous https://pumpingmarvellous.org/
• Stroke Association https://www.stroke.org.uk/

References

1.The Health Foundation. Did the NHS experience record pressures this winter? 2025. https://www.health.org.uk/reports-and-analysis/analysis/did-the-nhs-experience-record-pressures-this-winter

2. NHS England. National Early Warning Score (NEWS). https://www.england.nhs.uk/ourwork/clinical-policy/sepsis/nationalearlywarningscore/

3. NICE CKS. How should I diagnose seasonal influenza? 2024. https://cks.nice.org.uk/topics/influenza-seasonal/diagnosis/diagnosis/

4. Global Initiative for Chronic Obstructive Lung Disease. 2025 GOLD report; 2024. https://goldcopd.org/2025-gold-report

5. Yang HM, Ryu MH, Carey VJ, et al, for the COPDGene Investigators. Chronic Obstructive Pulmonary Disease Exacerbations Increase the Risk of Subsequent Cardiovascular Events: A Longitudinal Analysis of the COPDGene Study. JAHA 2024;13(11), e033882. https://doi.org/10.1161/JAHA.123.033882

6. UKHSA. Surveillance of influenza and other seasonal respiratory viruses in the UK, winter 2023-2024; 2024. https://www.gov.uk/government/statistics/surveillance-of-influenza-and-other-seasonal-respiratory-viruses-in-the-uk-winter-2023-to-2024/surveillance-of-influenza-and-other-seasonal-respiratory-viruses-in-the-uk-winter-2023-to-2024

7. UKHSA. Seasonal influenza vaccine uptake in frontline healthcare workers in England: winter season 2024 to 2025; 2025 https://www.gov.uk/government/statistics/seasonal-influenza-vaccine-uptake-in-healthcare-workers-winter-season-2024-to-2025/seasonal-influenza-vaccine-uptake-in-frontline-healthcare-workers-in-england-winter-season-2024-to-2025

8. NICE NG244. Asthma pathway (BTS SIGN NICE); November 2024. https://www.nice.org.uk/guidance/ng244

9. NICE NG115. Chronic obstructive pulmonary disease in over 16s: diagnosis and management; 2018 (updated 2019). https://www.nice.org.uk/guidance/ng115

10. Strange C, Tkacz J, Schinkel J, et al. Exacerbations and real-world outcomes after single-inhaler triple therapy of budesonide/glycopyrrolate/formoterol fumarate, among patients with COPD: Results from the EROS (US) Study. Int J Chron Obstruct Pulmon Dis 2023;18:2245–2256.

11. NICE NG209. Tobacco: preventing uptake, promoting quitting and treating dependence; 2021, updated February 2025. https://www.nice.org.uk/guidance/ng209

12. Alfaddagh A, Martin SS, Leucker TM,. (2020). Inflammation and cardiovascular disease: From mechanisms to therapeutics. American journal of preventive cardiology 2020;4:100130. https://doi.org/10.1016/j.ajpc.2020.100130

13. Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med 2023;33(1), 23–29. https://doi.org/10.1016/j.tcm.2021.12.001

14. Induruwa I, Hennebry E, Hennebry J, et al. Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation?. Eur J Intern Med 2022;98:32–36. https://doi.org/10.1016/j.ejim.2021.10.022

15. Bezati S, Velliou M, Ventoulis I, et al. Infection as an under-recognized precipitant of acute heart failure: prognostic and therapeutic implications. Heart Fail Rev 2023;28(4):893–904. https://doi.org/10.1007/s10741-023-10303-8