Will NHS England’s new Delivery Plan for Recovering Urgent and Emergency Care Services1 stop deaths resulting from delays in emergency care? That must surely be its highest priority. Emergency department performance and ambulance response times are at an all time low, and data describe failures of care and patient harm.2 Targets exist to hold healthcare systems to account and show the public what they are getting from healthcare funding. The emergency department four hour access target has not been met since 2015, and “corridor care” has become dangerously normalised. The continuing scourge of exit block in emergency departments has now spilt out of hospitals to the ambulance service, leaving patients stuck in the back of vehicles, on ambulance ramps, or, more terrifyingly, in their homes hoping that help will come. The NHS’s most basic promise to the public—to be there for them in an emergency—has been broken.
No one will quarrel with NHS England’s ambition in this new plan, but it is reasonable to ask why this plan will be any more effective than previous ones. The Urgent and Emergency Care Recovery 10 Point Action Plan was published in September 2021 and promoted as the recovery plan in the short and medium term.3 Many of the actions were related to the same topics covered in the January 2023 recovery plan. There were no signs that this plan reversed, or even slowed, the decline in performance. The new plan therefore starts in a worse place. Data from NHS Digital show that the four hour access target for type 1 emergency departments was 64% in September 2021 versus 49.6% in December 2022 and that over the same time period the number of 12 hour delays from decision to admit have increased from 5025 to over 54 000 in England.4 The average ambulance response time for category 2 calls, such as suspected strokes or heart attacks, has gone from 45 minutes in September 2021 to 1 hour 32 minutes in December 2022.56
What is different in this new plan? The new plan does have numbers—beds to be opened, new ambulances, and dedicated funding—but these rely on having enough staff to function. Staffing depends on “growing the workforce,” which is vague, and there is little in the plan about staff retention. The plans to increase clinician validation of calls to NHS 111, speed up discharges, and expand community services are all sensible but not new. The emergency department access target of 76% of patients to be seen within four hours by March 2024 is humiliatingly low, but sadly realistic.
But in the depths of this document there is something new—the commitment to publish monthly data on 12 hour delays from time of arrival in emergency departments. This positive statement is included under the heading of “transparency.” Why is this important? Clinicians have been demanding this for years. Up to now there has been monthly publication of 12 hour waits in emergency departments after the decision to admit and annual publication of 12 hour waits from time of arrival. The decision to admit has always been a misleading and easily manipulated point in the patient journey. In a few hospitals, the emergency medical team is “allowed” to make the decision, in others it must be the admitting team, and sometimes only the post-take consultant can decide. Decision to admit is meaningless to patients and has successfully concealed the increasing gridlock in emergency departments caused by the hospital bed shortage. In 2018-19 the official number of patients in England with 12 hour stays after a decision to admit was 3260, whereas the number of 12 hour stays from time of arrival was over 300 000.7 Before covid-19, large numbers of patients were experiencing exit block and harm as a result.
Data from an Emergency Medicine Journal study published in 2021, based on over five million patients attending emergency departments between 2016 and 2018, has informed discussion of excess deaths in recent weeks.8 The study found that, for every 72 patients waiting 8-12 hours from arrival, there was one excess death. This was a problem long before the pandemic, but, looking at the calculations and factoring in ambulance delays, the scale of harm is clear. Lives are being lost because the system is unable to deliver the care it should.
Publishing monthly 12 hour stay data can help hold systems to account. Shining a light on these delays will emphasise the extent to which vulnerable people are being exposed to harm through long waits, in emergency departments, in the back of ambulances, and waiting at home. We all hope it is not too late to introduce a performance target associated with improvement in flow. It would have been better to do this five years ago, when things were less pressured, because culture change takes time. The delivery plan says that “transparent, high quality data are important for improvement, providing insight across the whole journey.” Let’s hope this new public transparency can drive improvement in patient care and experience.