Aims Unprecedented winter pressures in 2017–18 led to cancellations of elective activity across the NHS and deteriorating population outcomes. East Midlands Clinical Senate undertook a review of the local planning processes to manage periods of increased demand

Methods A two-stage approach was adopted:

• Literature review of national guidance

• Interviews with four local organisations

Conclusion 25 papers were identified with guidance falling within 8 key themes: patient flow (n=13), communication and collaboration (13), demand (13), system capacity (12), funding (6), planning (6), patient safety (3) and staff training (3)

The interviews revealed that despite similar system and operational challenges, clinical solutions are not being shared between commissioners and providers at scale

More collaborative systems leadership approaches from commissioners during winter 2018–19 resulted in improved outcomes across the system

The ambulance service is uniquely placed as a provider which interacts daily across local systems and with providers. This enables operational and clinical relationships to be developed and there was evidence of how a strategic approach to learning and responding to this insight had enabled better performance and outcomes following the winter of 2017–18

The importance of looking after workforce and creating the best possible conditions for staff to do their best for patients was highlighted

Recommendations Better sharing of data and practices across the region

Systems embrace and develop innovative ways of working to facilitate holistic care

Commissioners should consider acting more as facilitators (enable change to occur and issues to be tackled) rather than regulators (seeking assurances on what has already happened)

Develop better relationships with ambulance services to ensure practices are robust and standardised

Improvements in rotas and increased investment in staff (both in terms of staffing numbers and improved skillset of each staff member)