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The case for a radical shake up of the Emergency Care system in England before winter – July 2020

In December 2019 being a patient in an Emergency Department was often grim. Emergency attendances were up over 5% from December 2018, four-hour performance was at an all-time low in and we saw the highest ever number of 12-hour waits. RCEM called for action to reverse the spiral of decline by investing in staff, space, and equipment in hospitals to help us look after patients properly. In many hospitals elderly patients were waiting in corridors to be admitted. Many of our existing Emergency Departments are understaffed, poorly designed and in need of repair. We welcomed plans announced in England for 40 new hospitals and engaged with the Clinical Review of Standards – the review being the only ‘game in town’ in England that might make things better for our patients and staff. We recognise the difficulties and limitations of the pilot process. We argued that a radical change was needed to an overwhelmed system that was increasingly unsafe for patients and unsustainable as a work environment for staff.

And then came COVID-19. Emergency Departments had to rapidly create capacity and segregated areas.
NHS 111 rose to the challenge of being the first point of contact. Primary Care dramatically changed the way it works so that many services could continue. Attendances to Emergency Departments fell, mostly in the lower acuity presentations. It is clear from the COVID experience that there is an opportunity to meet the needs of lower acuity patients in a different way, whilst at the same time some of the patients who need to come still do not. We must make sure that vulnerable patients are safe, and feel safe, to be cared for in hospitals. Preventing the spread of infection in Emergency Departments means that there is a moral imperative to ensure that we never see a return to crowding or ‘corridor care’. We cannot protect patients
and staff in overcrowded departments.

There is a potentially welcome change in the way patients access Urgent & Emergency Care. We have the 111 pilots, we have work going on to expand Same Day Emergency Care, we have a consensus building that patients well known to specialty teams with urgent care needs should be able to get advice without needing to wait in an ED. We are pleased that there is a joint statement from RCP, RCGP and SAM committing to improve the Acute Medical pathway. We recognise the challenges in providing a sustainable workforce and safe hospital capacity. We do have a commitment to refurbish and rebuild some of the most dilapidated Emergency Departments. These are exciting times for those of us working in Emergency Care as there is an opportunity to improve patient and staff experience, reverse the decline in safety and focus on the acutely ill, injured and vulnerable who are our core concern.

Now is the time to bite the bullet and change the way we measure emergency care. Patients who ‘breach’ the four-hour standard are left in limbo with no performance driver to reduce long stays. The standard is now 15 years old, has not been met since July 2015 and has almost entirely lost its ability to drive improvement. It is not unreasonable to consider alternatives. If we are going to have standards and targets (and we recognise that the health system has to be held to account) it is time to move to a more clinically driven framework – one focused on the needs of the sickest patients. The long process of the Clinical Review of Standards has moved us to this point, although there is still uncertainty about the effect on crowding. Moving away from a single target to a bundle of standards makes it easier to identify problems and avoid perverse incentives. We must never go back to overcrowded departments. Health services need to use the focus that COVID has provided to drive positive change. We need a better way of understanding patient care and patient flows in the Urgent and Emergency Care system. We need to try a new performance framework unencumbered by the four-hour standard if we are to improve care for our patients.

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