Summary
Emergency access to healthcare is in crisis. Unmet need in primary and community care and low capacity in hospitals and social care has left the emergency health services gridlocked and overwhelmed, unable to provide safe care. Waiting for care, patients experience distress and lengthy delays, leading to substantial clinical risk. Emergency healthcare, a key component in the national health service, has been allowed to degenerate, and it is likely to get worse. We see no sign that there is an adequate plan or the necessary leadership to address this.
Patients struggle to access care in the community, so feel they have no option but to use emergency services, attending Accident and Emergency departments (A&E), and calling ambulances. Hospitals are overcrowded and under-staffed, and so ambulances are stuck outside hospital waiting to hand over their patients, unable to respond to additional calls. Inside A&E, there are substantial delays before being treated or admitted. At the end of the experience, when ready to be discharged, patients often wait for community or social care to become available, remaining in beds that cannot then be accessed by other patients. While many patients experience only one delay along this chain, for others the process is a long waiting game at each stage.
In A&E, this waiting game has been widely underestimated. The number of patients waiting 12 hours or more in A&E is around five times higher than the number most regularly used. The data published monthly on waiting times exceeding 12 hours does not reflect the patient experience because the clock only starts when a clinician has made the decision to admit a patient to hospital, rather than when that patient entered A&E. This was described to us as “a fundamentally dishonest way of reporting data”. To demonstrate, in August 2022, 133,286 people waited in A&E for over 12 hours. Of these, over 100,000 were not reflected in the data published monthly.1
The scale of the challenge is substantial, and demographic change means that it will get worse. The problem is also complicated, created by unmet need at every level of the health and care services. Leadership is fragmented and under-ambitious, and there is no sign that the Government is adequately addressing the problem.
We need decision makers to work together to address this emergency, providing the system with the necessary resources. This means cross-government attention, and accountability from the Prime Minister down. In the short-term, therefore, we have recommended that a COBR Committee be assigned the responsibility to address the crisis in emergency healthcare.
In the long-term, we are clear that a substantial overhaul is needed, one which sets out a bold new operating model for the system as a whole, and which is backed by equally bold leadership.
Our action plan, which encompasses our recommendations, is set out in chapter 1.
Chapter 2, ‘A national emergency’, sets out the extent of the problem. It ends with the inescapable conclusion that many staff in emergency healthcare—recognising, as we have come to, that emergency healthcare is in crisis—will vote with their feet and leave the health service, compounding the problem.
Chapter 3, ‘What has gone wrong?’, examines how we reached this point. It considers unmet need, and failure to invest in preventative services. It also demonstrates the blockages caused by a failure to move patients through the system. There are far fewer beds in hospitals than a decade ago, and they are filling up with patients who cannot be discharged because there is inadequate provision of social care.
Chapter 4, ‘Leadership’, is where our key recommendations can be found. The Department of Health and Social Care and NHS England are deferring to extremely new structures (Integrated Care Systems) for solutions which these structures are not equipped to provide. We call for a bold new operating model, and strong, ambitious leadership from central Government.
Some problems have clear solutions. Alongside the long term shifts we have set out, we have made some more specific recommendations which, if implemented, would make a substantial difference to the parts of the emergency services to which they are relevant. They cannot stand alone.
In chapter 5, ‘Clarity of published data, we identify specific questions which require clarity, and how to address them. Chapter 6, ‘Right place, first time’, moves our focus to triage, and recommends a higher clinical presence within the non-emergency helpline, NHS 111. This would mean that fewer people would be sent to hospital from an abundance of caution: there would instead be informed clinical decisions and more patients empowered to care for themselves, at home. Chapter 7, ‘Collaboration’, looks at how police and fire and rescue services—the other ‘blue-light’ services—could be better supported and incentivised to collaborate with emergency health services. Chapter 8, ‘Best practice’, looks at how to empower and encourage the spread of interventions that have been proven to work. Currently, innovative methods of delivering emergency health services are trialled but rarely evaluated; and abandoned rather than celebrated. The ‘What Works Centre’, which could perform this function, does not do so.
The state of emergency healthcare is a national emergency. It requires an emergency response from the Government. Our action plan sets out how, in the short-term, the Government can address some immediate challenges, and in the long-term can begin developing a new model for emergency health services which are fit for purpose.