22 May 2023

NHS gridlock: facing the crisis in emergency care

Last year 1.65 million people waited more than 12 hours in A&E.

Photo by the Royal College of Emergency Medicine

At the end of last year photos of ambulance queues outside emergency departments dominated news bulletins and newspaper front pages. Those images merely represented a tangible visualisation of a much bigger and deeper crisis. This problem has not gone away.

Emergency departments are meant to be an entry point – often referred to as the hospital’s “front door” – a place for emergency care and assessment. Nurses and clinicians evaluate patients, give treatment where they can, and then discharge, transfer or admit patients.

People with the most serious conditions will be moved to another part of the hospital, admitted as an in-patient. But what happens when there is no bed available for them on the ward they need? Things grind to a halt and backlogs develop. Emergency departments begin to get crowded and the corridors fill with patients waiting, stranded on trolleys, often for hours.

In 2022 one in every 15 patients waited more than 12 hours in A&E from the moment they came through the door – over 1.65 million people. The people who waited longest were the elderly. In 2022 the average length of stay for a person over 80 years of age was 15 hours. This situation has become so “normal” it has its own term – “corridor care”. A recent survey showed that almost all emergency care nurses had provided care to patients in non-designated clinical areas (“corridor care”) in the past six months, and 70 per cent had done so every day.

The longer patients wait in emergency departments the higher the risk of harm or death. This has even been quantified: for every 72 patients who spend between eight and 12 hours from their time of arrival there is one excess death. At the start of the year, our analysis found there were an estimated 300-500 patient deaths happening each week across the UK as a result. This is the shocking reality of emergency care.

The system designed to treat those needing emergency care now finds itself in need of resuscitation. Our work shows that underpinning the present challenges facing our emergency care system is a significant shortfall of beds. We have calculated that the UK has 1.88 beds per 1,000 people. This is the second lowest compared with similar developed countries. (Germany has the highest, 7.8 beds per 1,000 people, and the EU average is 5.)

Bed occupancy across the UK is dangerously high: 92.6 per cent in England; 95.5 per cent in Wales; 88 per cent in Scotland. The recommended safe maximum level of bed occupancy is 85 per cent.

How have we got here?

From 2011 to 2019, 11,980 acute beds were cut in the UK (9,000 in England, 1,500 in Scotland, 1,100 in Wales and 380 in Northern Ireland). This was a deliberate policy decision in a move towards providing more care outside of hospitals. But social care has been so stripped back, under-funded and inadequately staffed that the beds we do have are occupied by patients who cannot be discharged safely and in a timely way.

The cuts to social care have driven up bed occupancy and together with the cuts to beds have driven dangerously long waiting times and overcrowding in emergency departments across the UK. In 2011 in England, the yearly average of four-hour performance at major A&Es was 95.1 per cent, with just 129 patients experiencing 12-hour waits. By 2019, the yearly average of four-hour performance at major A&Es dropped to 76.1 per cent and there was an annual total of 8,272 12-hour waits. That is an increase of 6,312 per cent. Obviously, there are other contributing factors to rising delays, but the clear correlation between beds and delays cannot be ignored.

In September 2022 NHS England pledged to open 7,000 additional beds (a mix of physical and virtual). In January 2023 the Urgent and Emergency Care Delivery plan reiterated that commitment to increase capacity by 5,000 actual hospital beds in 2023-24. Since September 2022, an extra 1,763 physical beds had been opened, but 1,615 of these have been closed since January 2023 – leaving just 148 additional physical additional beds. Meanwhile bed occupancy in England has remained above 94 per cent for six consecutive months.

None of the devolved governments have made commitments to increase the number of hospital beds. Both the Scottish and Welsh governments have initiatives to free up beds and improve flow, but these have not resulted in reducing bed occupancy. With the continued lack of a functioning government in Northern Ireland, no policy plans to increase capacity have been introduced.

Having sufficient beds numbers is crucial to a functioning health and social care system and an effective emergency care system. Right now, we simply don’t have enough. The Royal College of Emergency Medicine’s #ResuscitateEmergencyCare campaign includes long-term plans to build additional capacity within UK health and social care systems so patients can receive safe and timely emergency care.

Across the UK we need an increase of 9,728 beds (8,527 in England, 448 in Scotland, 582 in Wales, 171 in Northern Ireland) to ensure hospitals are run at a safe maximum of 85 per cent bed occupancy. In England this will require substantial capital funding to support the construction of new hospitals. While the current government pledged 40 new hospitals in 2019, building work has not yet begun on 33 of them, with many still waiting for budgets to be finalised.

Delays to care cause harm to patients – to people – injured, in pain, vulnerable, scared, seeking emergency care. It also creates further costs, because people who come to hospital later and have long delays in emergency departments are sicker and take longer to get better.

Those shocking images dominating the news bulletins need to be a wake-up call and a catalyst for change. With Keir Starmer setting out Labour’s vision for the NHS in a speech today, it is clear we are entering a pre-election period with manifestoes and policy pledges being formulated. All parties across the UK must put health and social care at the forefront of their agendas and follow our recommendations – including those around beds.

Inaction will only sustain the cycle of unacceptable “corridor care”, overcrowding and patient harm. Our patients deserve better, the public deserves better, and the Royal College’s members deserve better.