Most of us do not plan to visit the Accident and Emergency Department (A&E), yet any one of us could be a potential patient. Our emergency care system provides a vital service, ready to care for us when we need it most. At present, patients are being cared for in inappropriate spaces such as corridors. Patients should always receive emergency treatment in an equitable, safe, and timely manner. We now need long-term plans to tackle the lack of capacity across the health and social care system, so patients can receive safe and timely emergency care.
The Royal College of Emergency Medicine (RCEM) commissioned Ipsos to conduct an online poll of UK adults aged 16-75 to better understand their views on emergency care. The poll revealed that confidence in the UK Government’s approach to tackling long waits for patients in A&E is low, with 59% of respondents expressing a lack of confidence that the UK Government has the right policies to tackle long patient waiting times in A&E departments in hospitals. RCEM’s five priorities below for UK Governments will #ResuscitateEmergencyCare to ensure the emergency care system is there for us all in our time of need.
+ 1. Eradicate overcrowding and corridor care for patients
In 2022, more than 1.8 million patients across the UK spent twelve hours or more in Emergency Departments from their time of arrival. Just under half of the respondents surveyed recognise that they could be subject to overcrowding: 48% expressed that they did not feel confident they would be treated in an appropriate area if they personally had a medical emergency in the next week that required them to attend their local A&E.
Overcrowding happens when there is a lack of patient flow – or movement through the health and social care system – resulting in seriously unwell patients trapped in Emergency Departments. These patients are often left waiting for their care in inappropriate areas such as corridors and trollies. One of the primary causes of overcrowding is a lack of hospital beds: since 2010, more than 29,000 beds have been removed despite the increasing complexity of population healthcare needs. The public are acutely aware of this issue, with the majority of those surveyed reporting a lack of confidence in being admitted to a bed; 64% did not feel confident a hospital bed would be available if they personally had a medical emergency in the next week and needed to be admitted to hospital.
A lack of comprehensive social care provision exacerbates the problem. While medically ready to leave the hospital, many vulnerable patients may need help to recover through a social care package. This could entail support services and equipment to help with their daily needs, which may not be readily available. While waiting for this support, their hospital bed is unavailable to the next patient who urgently requires admission, resulting in further overcrowding.
Ambulance queues are a visible and harmful consequence of overcrowding. When Emergency Departments become crowded, they can no longer accept patients who arrive by ambulance, forcing them to wait outside. They are unable to return to the community to respond to other medical emergencies. At least two patients are at risk for every ambulance unable to offload: the patient in the ambulance and a further patient waiting for an ambulance. Overcrowding is dangerous, harmful, and undignified for patients. Receiving care in overcrowded conditions reduces the quality of care. While this may not have an immediate effect on the patient, there is a growing body of evidence demonstrating that overcrowding and long waits increase a patient’s risk of death after they have left the Emergency Department.
To improve patient flow, UK Governments must commit to a significant level of investment in the health and social care system to address the mismatch between the emergency healthcare needs of the population and the capacity of the NHS.
Acute Insight Series: Crowding and its Consequences. November 2021
Emergency Departments across the UK are not safely staffed, and clinicians working within them are stretched thin. For far too long, staff have had to bridge the gap between an under-resourced system and the quality of care that patients require. This has severe consequences: many clinicians work less than full time due to the relentless pressure, and for the same reason some leave the specialty, emigrate, or retire early. The NHS is struggling to retain its Emergency Medicine staff, adding more strain to an already pressured workforce. There are many different evidence-based interventions that can improve retention.
Emergency Medicine clinicians want to care for their patients in a safe and timely manner. However, they are often forced to care for patients who are left waiting in undignified and often unsafe, distressing conditions while managing an increasingly unsustainable workload. These workforce shortages are felt acutely by patients and the public. Just 18% of respondents surveyed agreed their local A&E had enough staff to care for them in a timely way, and only 23% of respondents expressed agreement that their local A&E had enough staff to care for patients in a safe way.
RCEM (2021) Scotland’s Emergency Medicine Workforce Census
RCEM (2023) Wales’ Emergency Medicine Workforce Census
Psychologically Informed Policy Project (2023) Key Recommendations for Retention and Workforce Wellbeing in Emergency Care.
As well as being the safety net for the public, Emergency Departments are often the only point of contact some patients have with the NHS as they are increasingly providing emergency care to the most vulnerable, such as patients who experience homelessness or mental health issues. In 2021-22 there were around twice as many attendances to Emergency Departments in England for the 10% of the population living in the most deprived areas, compared with the least deprived 10%. The deprivation of a population determines the demand for emergency care, yet research shows that resourcing for emergency care does not follow local health needs.
In no other part of the healthcare service are patients expected to endure extremely long waits for care, in a dangerous environment where they could potentially experience avoidable harm. Studies suggest people from deprived backgrounds are more likely to wait longer in Emergency Departments and receive fewer treatments. These conditions risk worsening health inequalities in the population. UK Governments need to work closely with local systems to ensure emergency care pathways are designed and resourced to meet the needs of every single patient.
Acute Insight Series: Mental Health Emergency Care, September 2022
Long patient waiting times can be a matter of life and death. These long waits can impact recovery, thus affecting all aspects of life, including the ability to work. Policymakers must understand what works and what doesn’t when implementing new initiatives to tackle long waits. Interventions should always be measured and evaluated, and this evidence used to amend and inform the design of policies.
In recent years, the NHS and UK governments have introduced interventions focused on reducing the number of patients who attend Emergency Departments. For example, in England, the NHS 111 First programme, launched during the pandemic, provided the public with the option to schedule an Emergency Department visit, with the explicit aim of managing overcrowding. Patients are still encouraged to use NHS 111 as their first port of call. Despite this, a third of respondents surveyed by Ipsos (in England, Wales, and Scotland) are not confident that NHS 111 will direct them to the most appropriate care service if they personally had an urgent healthcare need in the next week that wasn’t a life-threatening situation. Although it is essential to provide the public with a range of healthcare provision, patients stuck in crowded corridors are seriously unwell and require admission to hospital. These patients cannot be redirected to a GP, urgent treatment centre, and are unable to manage their own medical needs through an online or telephone service.
Meaningful performance metrics will support the NHS to improve the quality and safety of care. In England, the clarity around the future of the four-hour target – that at least 95% of patients attending Emergency Departments should be admitted, transferred or discharged within four hours – is welcome after years of being stuck in a performance vacuum. However, a target as low as 76% will incentivise hospitals to process patients who are not acutely unwell and therefore do not require admission, allowing them to meet the target. Performance against the four-hour target is in decline in every single UK nation; there must be a commitment to resourcing the system to meet this important standard. In England, we welcome the commitment to publishing the data on the numbers of patients waiting 12-hours or more from their time of arrival. To support patient safety and improve accountability, this data must be published on a monthly basis and be made available by Emergency Department. Additionally, disaggregating performance data – by different types of ED and the admitted and non-admitted pathway – will support transparency and better opportunities for benchmarking, ensuring that resource is distributed in the most efficient way.
RCEM (2022) Tip of the Iceberg: Long Stays in the Emergency Department