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Emergency healthcare: a national emergency Contents

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Chapter 2: A national emergency

9.Emergency health services are facing a crisis. Patients are delayed at every stage of trying to access emergency healthcare, with some left without clinical support for hours or overnight—exacerbating existing health problems and posing an unacceptable risk. Stories of ambulances being stuck outside of hospitals, unable to hand over patients and respond to further calls, have become common. In recent months there have been multiple reports of people dying while waiting for ambulances, and the number of people waiting to be seen in emergency departments has significantly risen.5

The extent of the problem

10.Barriers to accessing emergency healthcare have led to “a decline in public confidence”, with fewer than 40% of people saying they were confident in being treated in A&E or by an ambulance in a reasonable time.6 The figures prove the public right.

• In the West Midlands, the number of people dying waiting for ambulances has risen from one in 2020 to 37 between January and September 2022.7 Looking nationally, ambulances have been missing the target response times in almost every category every month since May 2021, with average response times for the second highest risk calls more than doubling since then.8
• Between 14 November–11 December 2022 an average of over 3,500 hours of ambulance staff time were lost every day to ambulance handover delays.9
• In October 2019, just 2% of patients handed over from ambulances to A&E waited over an hour. In October 2022, it was 18%: 52,000 patients.10
• In October 2022, 45% of patients waited longer than four hours in A&E. NHS England stated this was “the lowest reported performance since the [data] collection began” in June 2015.11
• In November 2022, 37,800 patients waited 12 hours between the decision to admit them into A&E and being admitted. The real number of people waiting 12 hours or more in A&E is likely much higher (see chapter 5, ‘Clarity of published data’.)

Figure 1: Patients waiting 12 hours or more from decision to admit to admission

Royal College of Emergency Medicine, ‘ Data & Statistics’: https://rcem.ac.uk/data-statistics/ [accessed 9 January 2023]

Figure 2: Ambulance response times to category two calls

NHS England, ‘Average daily number of available beds, by sector, England 1987–88 to 2009–10’ (29 July 2010): https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.england.nhs.uk%2Fstatistics%2Fwp-content%2Fuploads%2Fsites%2F2%2F2022%2F12%2FAmbSYS-time-series-ending-20221130.xlsx&wdOrigin=BROWSELINK [accessed 9 January 2023]. This graph shows the averages (mean) waiting times and 90th centile waiting times for category two ambulance responses only. The target response time for these calls are for the mean response time to be 18 minutes, and the 90th centile response time to be 40 minutes. The graph shows that neither target has been met in the timeframe shown.

11.Delays create significant clinical risk. In June 2022, the Healthcare Safety Investigation Branch stated that delays handing over patients from ambulance crews to A&E were “causing life-threatening harm to patients.”12 The Association of Ambulance Chief Executives put it starkly: “some people are dying because we cannot reach them in time, others are experiencing worsening condition and poorer outcomes when treatment has been delayed”.13 Martin Flaherty, the managing director of the Association, has stated:

“These crippling delays are a twin threat—they cause significant harm to patients who are forced to wait in the back of our ambulances, while our crews are stuck and therefore unable to respond to patients who need us out in the community … patients are dying and coming to harm as a result on a daily basis.”14

The Healthcare Safety Investigation Branch published an interim bulletin in November 2022. It found that “extended ambulance response times and delays in transferring patients to the right place of care … are impacting on patient safety throughout the healthcare system.”15

12.The emotional impact of long delays in treatment is considerable and our evidence reflected that, repeatedly referring to fear, distress and suffering for patients.16 We have outlined some case studies below.

Box 3: Experiences of the emergency healthcare system

A care home patient with a fractured hip was categorised as being “in a place of safety”, and care home staff were told not to move the person. They were left on the floor for over eight hours before an ambulance arrived, with little beyond paracetamol for treatment.17 An 87 year-old man with prostate cancer waited 15 hours for an ambulance to arrive after a fall. Delays and advice from call handlers not to move him meant he was lying outside overnight, in a makeshift tent his family built using items including a football goal and an umbrella. His injuries included a fractured pelvis and seven cracked ribs.18 A case study shared during the inquiry set out someone’s experience of calling an ambulance for their mother: “My Mom had a fall at home. I called an ambulance and Mom was left on a cold kitchen floor for 21 hours until the ambulance came the following day. Even though I telephoned 999 five times and basically told them that I thought Mom had fractured something I was told stop ringing unless anything changed in her condition … Mom has osteoporosis of the spine, hips and knees and I advised them of this but she was still left on the floor.”19

13.The state of emergency healthcare is a national emergency. The substantial delays that patients face when trying to access emergency health services create considerable emotional distress and an unprecedented clinical risk.

Impact on the workforce

14.The emergency health workforce faces significant challenges, including shortages,20 low job satisfaction and retention rates,21 and poor health.22 Ambulance staff were described as “overwhelmed”,23 and “fatigued and depleted”.24 In the NHS as a whole there is a vacancy rate of 9.7%, amounting to over 133,000 vacant posts, the highest vacancy level in the last five years. Within ambulance services, there are over 3000 vacancies, a 6% vacancy rate, and in acute care settings there are 90,967 vacant roles (9.1%).25 The resulting overwork may help explain the finding of the 2021 NHS staff survey that 67% of paramedics had felt unwell as a result of work-related stress in the last 12 months.26

15.We heard that retention in emergency health services is a major issue, with staff leaving for other roles as the problems in the service negatively affect staff.27 Daren Mochrie, Chair of the Association of Ambulance Chief Executives, gave a compelling explanation of why.

“If I were back in an ambulance now, starting a shift at 7 am, not getting time to check my vehicle and my drugs, being sent out to one patient after the next, standing in a hospital corridor for six or seven hours, only seeing one patient and not doing the clinical role that I am employed to do, missing meal breaks, not getting breaks and being kept late every night of the week because I am stuck wherever I am stuck, not seeing my family—all that would grind me down, and it will grind staff down.”28

16.Pay concerns were also repeatedly raised, not only by union bodies but by organisations representing leadership, such as the Association of Ambulance Chief Executives.29 Frustration about pay and terms and conditions of work has also been demonstrated through ambulance staff strikes at nine of the ten ambulance trusts in England30 and the first ever nationwide nurses’ strike.31 In November 2022, the Nuffield Trust reported that all NHS staff have seen a 4.5% pay cut in real terms since 2010.32

17.This is no surprise to us. Problems in retention, wellbeing, job satisfaction and pay exist across the public services workforce, as we explored in our report Fit for the Future? Rethinking the public services workforce.33 That report also highlighted unacceptable levels of bullying and harassment in the workforce; borne out by the NHS staff survey which found that 27.5% of staff had experienced bullying, harassment or abuse in the last 12 months from patients, service users or other members of the public. 11.6% had experienced it from managers, and 18.7% from other colleagues.34

18.The emergency healthcare workforce is under unprecedented strain. Without concerted action to address the emergency in the system, many of them will leave the health service.

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