Emergency healthcare: a national emergency Contents

Chapter 3: What has gone wrong?


19.We heard that there has been significant long-term growth in demand for emergency health services.35

Increasing demand for emergency health services

20.There is a long-term increase in the number of people accessing A&E and ambulance services:

Figure 3: A&E attendances graph

NHS England, ‘ A&E Attendances and Emergency Admissions’: https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/ [accessed 9 January 2023]

Figure 4: Ambulance incidents

NHS England, ‘Ambulance Quality Indicators’: https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ [accessed 9 January 2023]

Figure 5: 999 and 111 calls

NHS England, ‘Ambulance Quality Indicators’: https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ [accessed 9 January 2023], NHS England, ‘NHS 11 Minimum Data Set 2020–21’: https://www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/nhs-111-minimum-data-set/nhs-111-minimum-data-set-2020-21/ [accessed 9 January 2023], NHS England, ‘Integrated Urgent Care Aggregate Data Collection (IUCADC including NHS111) Statistics Apr 2022–Mar 2023’: https://www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/integrated-urgent-care-aggregate-data-collection-iucadc-including-nhs111-statistics-apr-2022-mar-2023/ [accessed 9 January 2023]

21.The long-term increase in demand is not enough to explain the step-change in waiting times seen in the 12–18 months prior to December 2022; the number of ambulances waiting for an hour outside A&E is five times higher than two years ago.

Type of demand

22.The number of patients with severe conditions who urgently need to be seen (high-acuity patients)40 has increased by 11% over a two year period.41 There is also a substantial rise in the number of mental health attendances to A&E—an increase of 133% between 2009–10 and 2018–19.42 This was described to us as “unplanned primary care” and it had, we were told, increasingly become a feature of ambulance services’ work.43

Unmet need in primary care

23.Several witnesses suggested that an increase in demand for emergency services has arisen because of barriers in accessing care elsewhere, including primary care and mental health services.44

24.Preventative health services have seen significant cuts. The Health Foundation report that the Public Health Grant45 has been cut by 24% on a real terms per person basis since 2015–16, with greater cuts falling in more deprived areas.46 In October 2022, one in five patients, over six million people, faced a wait of over two weeks between booking their primary care appointment and attending it, whilst almost 2 million people waited over 28 days.47 Similarly, a third of people in contact with mental health services saying they had not seen their care providers often enough for their needs.48

25.These barriers to accessing care drive demand for emergency care. Dr Adrian Boyle, President of the Royal College of Emergency Medicine stated: “a lot of people do come to an emergency department because it is the only place they can access services.”49 This has been borne out by the GP Patients Survey 2022, which found that more than 1 in 10 people who could not get an appointment at their GP surgery went to A&E.50 The Frequent Caller Action Network described frequent callers to 999 services as “a vulnerable patient cohort who present with multiple unmet complex physical health, mental health and/or social care needs”.51 Even when patients do not go straight to emergency services when they cannot access primary care, they may still need to attend A&E or to call 999 if their conditions deteriorates.52 The same is true of patients facing long waits to access elective care.53

Figure 6: Percentage of patients who felt they had seen NHS mental health services often enough for their needs in the last 12 months

Care Quality Commission, ‘Community mental health survey 2022’ : https://www.cqc.org.uk/publications/surveys/community-mental-health-survey [accessed 9 January 2023]. The number of people who answered “yes, to some extent” has remained consistently around 31%.

Figure 7: Elective treatment waiting list

British Medical Association, ‘NHS backlog data analysis’: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis [accessed 9 January 2023]

Figure 8: GP waiting times

NHS England, ‘Appointments in General Practice, Experimental Statistics October 2022’ (November 2022): https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/october-2022 [accessed 10 January 2023]. The number of appointments categorised ‘unknow / data quality’ was 27,238, which amounts to less than 1%.

Bed capacity

26.The number of beds available in hospitals is an important factor in care capacity. The Royal College of Emergency Medicine report:

“The gradual loss of acute beds within hospitals is a key contributing factor: since 2010, over 29,000 hospital beds have been removed from the system, despite no reduction in demand. The UK has one of the lowest numbers of beds per capita [among] OECD nations.”54

27.The King’s Fund report that “the total number of NHS beds has more than halved over the past 30 years.”55 The total number of beds has dropped from around 299,000 in 1987–88 to 128,800 in 2022–23. The latest NHS data shows that, within this, the number of hospitals beds for general and acute care has fallen by 43% from 180,900 to 102,300.56

28.Ideally, we were told, there should be an 85% occupancy rate for acute beds (with 15% unoccupied). This would allow patients to move effectively through hospitals and reduce overcrowding.57 In September 2022, 93.6% of acute beds were occupied in England—some significant way from the stated ideal.58

29.The bed capacity problem is clearly recognised by the Government. The Minister for Health and Secondary Care, Will Quince MP, stated: “We are increasing hospitals this winter by 7,000 additional acute and other beds. About 2,500 of those will be virtual ward beds”.59 However, virtual wards are not additional beds in hospitals, but “remote health services which support patients to remain at home”.60 They do not represent a physical bed in a hospital, although hospital doctors may monitor patients at home remotely.61

30.Even with these ‘virtual ward’ beds included, the planned increase leaves the NHS 22,000 beds short of 2010 levels and does not provide a longer-term boost to capacity. Increasing the number of available beds will mean little if the staffing issues outlined in chapter 2 are not addressed. Sarah Scobie, Deputy Director of Research at the Nuffield Trust, argued that “there are not enough staff to keep more beds open. It is not just a question of the physical space and physical rooms; it is about the staffing”.62

31.In many cases, patients are attending emergency care services because they have—or feel they have—no alternative. The models for primary and community care are broken.

32.The Department of Health and Social Care should continue working to increase the number of physical beds in hospitals. This work must ensure that additional beds are sufficiently staffed.

Patient flow

33.Several witnesses highlighted problems in how patients moved through and out of hospital. Of the patients who arrive in A&E, some are admitted to hospital wards and most will ultimately need to be discharged.63 Dr Adrian Boyle, President of the Royal College of Emergency Medicine, argued:

“The reason why we are seeing these very long delays to offloading ambulances and handover delays is that our hospitals are full … the problems are largely all about the flow through emergency departments.”64

34.Patients are often not being discharged when they are clinically ready, remaining in hospital for longer than they need to (with associated risk of infection).65 This leads to a shortage of available beds in hospital wards for patients to be admitted from A&E, leading to crowding and long waiting times.66 One patient described their experience with this:

“[I] was considered ill enough for admission. No bed. Treatment [was] sporadic and a total of 24 hours spent in A&E finally requesting to be allowed home as was in too much pain and discomfort to remain sitting on a hard chair any longer. Traumatic experience.”67

35.Overcrowded emergency departments may be unable to accept patients from ambulances, which are often then stuck with patients outside hospitals68 and unable to respond to other callers.69 As Sarah Scobie, Deputy Director of Research at the Nuffield Trust, said, “To understand the pressures on urgent care, the front door of the hospital and the situation with ambulances, you need to start at the back door of the hospital and look at what is going on in terms of patient discharge.”70

36.The scale of this problem is significant. The Institute for Government estimated that on an average day between 29 November 2021 and 31 August 2022, 12.4% of general and acute beds in hospitals in England were occupied unnecessarily: patients clinically ready for discharge, but with nowhere to be discharged to.71 Data for April 2022, obtained via a freedom of information request, indicated that 65% of delays in discharging patients were due to waits for services such as social care or community healthcare to be available, to ensure the discharge was safe.72

Availability of social care

37.Health Education England noted the difficulty in making discharge decisions: “one of the most complex decisions a health care professional has to make is whether someone can be safely maintained at home”.73 Others highlighted concerns about sending a patient home when other clinical support may not be available, such as late at night or on weekends.74 Dr Vin Diwakar, medical director for transformation and secondary care at NHS England, said:

“You hear lots of stories from acute trusts where … all the clinical care has been delivered that can be delivered in a hospital setting, and the community services or local authority care or the care home cannot accept the patient on a Saturday or Sunday.”75

38.A lack of social care capacity has been widely reported. 90% of directors of adult social care do not believe there is the funding or workforce to meet the care costs of older and disabled people in their area.76 The Government recognises the importance of this for healthcare settings. The Minister for Health and Secondary Care, Will Quince MP, stated that “much of this hinges on social care”.77 The Parliamentary Under Secretary of State at the Department of Health and Social Care, Lord Markham, has stated that lack of capacity in social care “is what is behind the 13% of beds that are blocked”.78 An additional complexity is that regulation prohibits care homes from accepting patients past identified levels: Len Richards, Chief Executive of Mid Yorkshire Hospitals NHS Trust, shared examples of care homes refusing admissions from over-full hospital wards because it would put their accreditation at risk.79

39.The crisis in emergency healthcare is a symptom of fundamental weaknesses arising from inadequate capacity across primary, community, and hospital and social care settings. A new model for primary care is needed.

Short-term measures to support social care

40.The Government has taken steps to support swifter discharges into social care. Action includes a £500 million Adult Social Care Discharge Fund which will be distributed between local authorities and integrated care boards (see paragraphs 67–78). This funding is expected to be pooled into the Better Care Fund, which aims to ensure “greater join up of health, social care and housing services” to “enable people to stay well, safe and independent at home for longer”.80 Alongside this, in January 2023, the Government announced an additional £200 million for NHS services to “immediately buy short-term care places to allow people to be discharged safely from hospitals”.81 Given demographic change and the resultant need for further capacity in social care (see paragraph 52), this join up between health and social care funding is welcome. A similar join up occurred during the COVID-19 pandemic, when the NHS was able to use funding to pay for follow-on costs in adult social care or home care costs for up to six weeks after discharge from hospital. This aimed to support social care providers to be able to accept patients from hospitals.82

41.The Adult Social Care Discharge Fund, however, is not new funding: it comes from existing health and care budgets.83 It is also a short-term measure, with funding released in December 2022 and January 2023. The Government has stated that the discharge fund can be used “to boost general adult social care workforce capacity through staff recruitment and retention”84 but little information is available about how new staff, including agency staff, recruited using that funding will be paid once the discharge fund ends, which suggests that progress may halter after that time. he Adult Social Care Discharge Fund has been described by the Association of Directors of Adult Social Services as “too little, too late”.85 While the £200 million announced in January 2023 appears to be additional funding, stakeholders have criticised the timing of the decision, with, the NHS Confederation arguing that “the government is playing catch up” during a crisis.86

42.The Government should introduce further incentives to enable discharge at the right time for patients, freeing up hospital capacity. This could include further use of NHS budgets to cover social care costs.

Longer term support

43.Within the Autumn statement, the Government has announced a funding increase for the social care sector. This was an increase of up to £2.8 billion in 2023–24, and £4.7 billion in 2024–25.87 While additional support for social care is welcome, it does not meet the £7 billion annual increase called for by the House of Commons Health and Social Care Committee in 2020.88

44.While the Government’s interventions to boost capacity in social care are welcome, they will not be sufficient to fully address the problem.

35 Written evidence from the Department of Health and Social Care (AES0014), QQ 1–2 (Prof Peter Murphy), QQ 12, 24, 26

36 Written evidence from the Department of Health and Social Care (DHSC) (AES0014). Comparisons with data before 2017 are difficult due to changes in how cases were recorded.

37 Written evidence from the Department of Health and Social Care (DHSC) (AES0014). Attendances peaked in 2019–20 at 25 million, before dropping to 17.4 million in 2020–21, the first year of the COVID-19 pandemic.

38 NHS England, Ambulance Quality Indicators Data 2022–23 (December 2022): https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ambulance-quality-indicators-data-2022–23/ [accessed 21 December 2022] Callers are directed to ambulance control rooms when they call 999 and request an ambulance.

39 NHS England, NHS 111 Minimum Data Set 2020–21 https://www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/nhs-111-minimum-data-set/nhs-111-minimum-data-set-2020–21/ [accessed 21 December 2022] and NHS England Integrated Urgent Care Aggregate Data Collection (IUCADC including NHS111) Statistics Apr 2022–Mar 2023 (December 2022): https://www.england.nhs.uk/statistics/statistical-work-areas/iucadc-new-from-april-2021/integrated-urgent-care-aggregate-data-collection-iucadc-including-nhs111-statistics-apr-2022-mar-2023/ [accessed 21 December 2022]. See also Q 49 (Dr Vin Diwakar).

40 NHS England, Guidance for emergency departments: initial assessment (August 2022): https://www.england.nhs.uk/guidance-for-emergency-departments-initial-assessment/ [accessed 21 December 2022]

41 This means that A&E departments are seeing 11% more patients classified as having the highest risk category than they were two years ago. See NHS England, Ambulance Quality Indicators: https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ [accessed 9 January 2023]. NHS England data demonstrate that in 2019–20 there were 449,600 category 1 incidents, but in 2021–22 there were 514,400, an increase of 11%. See also QQ 24–25 (Daren Mochrie), Q42 (Victoria Vallance), written evidence from Dr Alison Porter (AES0034) and NHS Providers (AES0010).

42 Written evidence from the Royal College of Emergency Medicine (AES0017)

43 Q 6 (Prof Leo McCann)

44 For primary care, see: written evidence from the College of Paramedics (AES0016), and the NHS Confederation (AES0010), and Health and Social Care Committee, The future of general practice (Fourth Report, Session 2022–23, HC 113). For mental health, see: Written evidence from the Royal College of Emergency Medicine (AES0017); Open University Centre for Policing Research and Learning (AES0011) and HM Inspectorate of Constabulary and Fire & rescue Services (AES0012).

45 A grant from the Department of Health and Social Care to local authorities to improve health in local populations.

46 The Health Foundation, Public health grant (October 2022): https://www.health.org.uk/news-and-comment/charts-and-infographics/public-health-grant-what-it-is-and-why-greater-investment-is-needed [accessed 29 December 2022]. See also Q 1 (Prof Peter Murphy).

47 NHS Digital, Appointments in General Practice, October 2022, (November 2022): https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/october-2022 [accessed 29 December 2022]

48 NHS Digital, Mental Health Bulletin, 2021–22 Annual report (November 2022): https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-bulletin/2021–22-annual-report/main-findings#changes-since-march-2020 [accessed 29 December 2022]

49 Q 37 (Dr Adrian Boyle)

50 NHS, GP Patient Survey: https://gp-patient.co.uk/ [accessed 29 December 2022]. See also written evidence from the Open University for Policing Research and Learning (AES0011).

51 Written evidence from the Frequent Caller Action Network (AES0008)

52 Q 37 (Dr Adrian Boyle)

53 Written evidence from Unison (AES0039)

54 Written evidence from the Royal College of Emergency Medicine (AES0017)

55 The King’s Fund, NHS hospital bed numbers: past, present, future (November 2021): https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers [accessed 29 December 2022]

57 Q 31 (Dr Adrian Boyle), Q 64 (Dr Vin Diwakar)

58 Q 31 (Dr Adrian Boyle)

59 Q 61 (Will Quince MP)

60 NHS England, What is a virtual ward?: https://www.england.nhs.uk/virtual-wards/what-is-a-virtual-ward/ [accessed 30 December 2022]

61 See chapter 8 ‘Best practice’.

62 Q 46 (Sarah Scobie)

63 Written evidence from the Care Quality Commission (CQC) (AES0023) and Q 41 (Sarah Scobie)

64 Q 31 (Dr Adrian Boyle)

65 Longer stays in hospitals can also worsen patients’ health, see 41 (Sarah Scobie).

66 Q 57 (Prof Julian Redhead) and written evidence from the Department of Health and Social Care (DHSC) (AES0014)

67 Written evidence from Healthwatch England (AES0006)

68 Q 57 (Prof Julian Redhead),

69 Written evidence from the Department for Health and Social Care (DHSC) (AES0014)

70 Q 41 (Sarah Scobie)

71 Institute for Government, Performance Tracker: Hospitals (17 October 2022): https://www.instituteforgovernment.org.uk/publication/performance-tracker-2022/hospitals [accessed 29 December 2022]. See also written evidence from Care England (AES0009).

72 Q 41 (Sarah Scobie). The Nuffield Trust, Hospitals at capacity: understanding delays in patient discharge (October 2022): https://www.nuffieldtrust.org.uk/news-item/hospitals-at-capacity-understanding-delays-in-patient-discharge [accessed 29 December 2022] shows that 15% await a permanent bed in a care or nursing home, 22% await short term rehabilitation, 24% await home care and 5% await a community care agreement on discharge plan.

73 Written evidence from Health Education England (AES0036)

74 Q 40 (Dr Adrian Boyle); see also written evidence from HM Inspectorate of Constabulary and Fire & Rescue Services (AES0012), Royal College of Paediatrics and Child Health (AES0041).

75 Q 64 (Dr Vin Diwakar)

76 Association of Directors of Adult Social Services, Autumn Survey Report 2022: https://mcusercontent.com/83b2aa68490f97e9418043993/files/0c1fb681-8955-aab3-9c2f-f9a3979ea32c/ADASS_Autumn_Survey_Report_Publication_15_November_2022.pdf [accessed 9 January 2023]. See also Skills for Care, ‘The state of the adult social care sector and workforce in England’ (October 2022): https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx [accessed 9 January 2023]. We have previously highlighted staffing issues in social care, reporting significant challenges in recruitment and retention, with concerns including low pay, lack of recognition, poor wellbeing, and lack of career progression. See: Public Services Committee, ‘Fit for the future?’: Rethinking the public services workforce (1st Report, Session 2022–23, HL Paper 48)

77 Q 61 (Will Quince MP)

78 HL Deb, 9 November 2022, cols 634–637 [Lords Chamber]

79 Q 27 (Len Richards)

80 Department of Health and Social Care, Press release: Better Care Fund framework 2022 to 2023 published (19 July 2022): https://www.gov.uk/government/news/better-care-fund-framework-2022–23-published [accessed 30 December 2022]

81 Department of Health and Social Care, ‘Up to £250 million to speed up hospital discharge’ (9 January 2023): https://www.gov.uk/government/news/up-to-250-million-to-speed-up-hospital-discharge [accessed 12 January 2023]

82 Department of Health and Social Care, ‘Press release: More than half a billion pounds to help people return home from hospital’ (21 August 2020): https://www.gov.uk/government/news/more-than-half-a-billion-pounds-to-help-people-return-home-from-hospital [accessed 30 December 2022]

83 HSJ Intelligence, ‘No new money in Coffey’s £500m winter social care fund’ (22 September 2022): https://www.hsj.co.uk/finance-and-efficiency/no-new-money-in-coffeys-500m-winter-social-care-fund/7033210.article [accessed 30 December 2022]

84 Department of Health and Social Care, ‘Letter to the health and social care sector from the Minister for Care’ (18 November 2022): https://www.gov.uk/government/publications/adult-social-care-discharge-fund/letter-to-the-health-and-social-care-sector-from-the-minister-for-care--2 [accessed 30 December 2022]

85 Local Government Chronicle, ‘Discharge fund roll out ‘too little, too late’, warns Adass’ (12 November 2022): https://www.lgcplus.com/services/health-and-care/discharge-fund-roll-out-too-little-too-late-warns-adass-21-11-2022/ [accessed 30 December 2022]

86 NHS Confederation, ‘Government playing catch up on NHS crisis, say health leaders’ (9 January 2023): https://www.nhsconfed.org/news/government-playing-catch-nhs-crisis-say-health-leaders [accessed 12 January 2023]

87 HC Deb, 17 November 2022, cols 844-893 [Commons Chamber]

88 Health and Social Care Committee, Social care: funding and workforce (Third Report, Session 2019–21, HC 206)

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