(First published in Roy Lilley’s nhsManagers newsletter)

Sometimes it’s a bit like Game of Thrones in the NHS. Either winter is coming, or we’re already in the depths of it with no end in sight.

Right now it’s the hottest week of the year, so winter must be coming. What can we expect when it arrives?

We can expect the new year to start off with high demand for medical emergency care, which tails off in the spring. Then in the summer, demand will be higher for trauma. The exact details will vary locally, but it’s easy enough to measure, and this emergency demand has first call on your beds.

Next up are the urgent inpatients – such as those with cancer. They take second call on your beds.

Finally we have routine inpatients. We can choose when to treat them, as long as they don’t breach a waiting time target. So we can admit fewer routines when the beds are full of emergencies, and more when the pressure eases off.

That way, we can plan to run the hospital all year round with constant beds, and avoid the high cost of escalation beds and agency staff.

Now… if we’re going to ease off on routine inpatients in winter, then that’s a good time to crack on with some daycases.

So we can plan extra daycase work whenever we’re expecting to operate on fewer inpatients. That way, our surgeons can keep busy all year round, doing the work they love, without being frustrated by the predictable bed crises.

So far so good. But there’s more. If we treat fewer routine inpatients in winter, waiting times are going to go up. So we need to get the waiting list nice and small before Christmas – then it has room to grow over winter but without breaching the target.

And that is why winter is coming. Because we need to plan our autumn backlog clearance to achieve that nice small waiting list. And we need to do it now, while there is still time.

What if we don’t? Then the inpatient waiting list will be too big at Christmas, we’ll end up trying to do inpatient waiting list initiatives in February when the beds are full, and cancellations and waiting times will go through the roof. Oh, and everybody will be fighting each other for scarce resources.

See? It really is like Game of Thrones. Now, where did I leave my dragon?