Tag: emergency care

RCEM: Emergency care ‘in dire crisis’

Devolved governments call for more cash for NHS pay

The UK Government has been urged to increase the amount of funding available for NHS pay.

Ahead of the Autumn statement, Scottish Health Secretary Humza Yousaf and Welsh Health Minister Eluned Morgan have written to UK Health Secretary Steve Barclay to ask for additional funding to help avert strike action this winter in the NHS.

The letter reads:

“We wanted to write to you in advance of the Chancellor’s Autumn Statement on 17th November to once again make the case for additional funding for our hardworking NHS staff.

“In recent weeks the Deputy First Minister of Scotland and the Welsh Government Minister for Finance and Local Government have written to His Majesty’s Treasury to make clear the need for additional funding for public services.

“The Royal College of Nursing have announced a sweeping legal mandate for industrial action across the UK. In Scotland, they have joined several other unions representing NHS staff in gaining a legal mandate for industrial action with ballots expected to confirm a mandate in the rest of the UK.

“The risk to the NHS of industrial action this winter is profound, and we all need to do all we can to avert industrial action in any form. The NHS across the UK continues to feel the effects of the pandemic as it recovers and remobilises, and any action is likely to have catastrophic effects in all parts of the UK.    

“We are experiencing a cost of living crisis and the anger of NHS staff is entirely understandable. Sky rocketing inflation combined with high interest rates, a direct result of the havoc caused by the UK Government’s mini-budget, means that we are simply unable to come close to matching the expectations of NHS staff across the country. While the support provided by the UK Government on areas such as support for energy bills is welcome, it has not gone nearly far enough.

“Media reports suggest that the Chancellor is considering reimposing austerity on the people of the UK again, for which there is no mandate, through extensive spending cuts. That would be a disaster for our public services, including the NHS, at a time when they need more investment, not less.

“We would therefore implore you to work with us to make the case to the Chancellor in advance of his Autumn Statement for increased funding for the NHS and the devolved governments as a whole, primarily to pay our hard working NHS staff a fair pay rise in the face of the cost of living crisis this winter, and avoid what could be catastrophic industrial action in the NHS.”

Responding to the latest Emergency Department performance figures published by NHS England for October 2022, Dr Adrian Boyle, President of the Royal College of Emergency Medicine, said: “The crisis in Emergency Care is dire. October saw nearly 44,000 patients face a 12-hour DTA wait – we know 12-hour waits measured from decision-to-admit are just the tip of the iceberg and hides the reality.

“We know far more patients wait for 12-hours measured from their time of arrival. NHS England and the Department of Health and Social Care will still not commit to publishing this data, despite it being collected by all Trusts. We believe this is a barrier to tackling the root of the crisis.

“We know excessively long waits and dangerous crowding are associated with patient harm and increased risk of mortality. Scientific studies have shown that there is one death for every 67 patients waiting between eight and 12-hours from their time of arrival in the Emergency Department.

“The ONS continue to report worryingly high excess mortality figures and we believe that dangerous crowding, long delays, and the crisis in urgent and emergency care are contributing to a significant proportion of these excess deaths.

“We are increasingly concerned about the winter and the health system’s ability to cope. We are already at 94.3% bed occupancy for all general and acute beds and each month patients face the longest waits on record. The system is failing in its core function – the quick and effective delivery of emergency care.

“We need meaningful action now – sticking plasters like setting up tents or handover units will do nothing to resolve these long-waits and may actually cause more harm to patients. We know we need to be able to admit patients, we know ambulances need to handover patients quickly, we agree that it is vital that ambulances must return to Urgent and Emergency calls in the community – but to achieve this we must tackle the issue of poor flow in our hospitals.

“Many patients in hospital no longer meet the criteria to reside, they are occupying beds to which we could be admitting patients. Around 13,000 people are in hospital unable to be discharged. We urgently need an effective social care workforce to help with the discharge of these patients, so we can admit patients, receive patient handovers promptly, and get ambulances back out to the community.

“It is crucial that those in power understand that this is not a demand issue, attendances are not causing crowding and long waits. Crowding and long waits are a consequence of the inability to move patients through the hospital, a consequence of patients who are unable to be discharged because of severe cuts to social care.

“If you can’t discharge patients, beds are indefinitely occupied and the whole system is blocked. The government must get a grip of the social care crisis to fix flow.”

Commenting on the news that the RCN have voted in favour of strike action, Dr Adrian Boyle said: “In Emergency Medicine there is a retention crisis, particularly amongst our nursing colleagues.

“Emergency Medicine nurses are a critical part of the workforce – EM is a team sport. We know and understand that many EM staff, including nurses, are burned out, exhausted and overwhelmed.

“They are skilled, competent professionals who deliver excellent care for our patients. It is vital that our nursing colleagues feel valued and appreciated.”

The latest Emergency Department performance figures published by NHS England for October 2022 for show:

  • There were 1,399,916 attendances at major Emergency Departments
    • This represents a 7.5% increase compared with September 2022, and a 1.7% increase compared with pre-pandemic levels (October 2019)
    • There were 2,000,493 attendances at all Emergency Care facilities
  • 43,792 patients were delayed for 12-hours or more from decision to admit to admission
    • This is the highest number of 12-hour waits on record
    • It is 520% higher than the same month last year, October 2021, and it is 5932% higher than October 2019
    • There have now been 255,334 12-hour DTA stays recorded so far in 2022 – three times as many as were recorded in the 137 months prior to 2022
  • Four-hour performance at major Emergency Departments was 54.8%, this is the worst four-hour performance on record
    • This is a 7.1 percentage point decrease from October 2021, and a 19.7 percentage point decrease compared with October 2019
  • Type 1 admissions stood at 366,964 (a daily average of 11,838)
  • 26.2% of type 1 attendances were admitted, this is a one percentage point decrease from September 2022
  • 150,922patients spent more than four hours in an Emergency Department from decision to admit to admission (also referred to as ‘trolley waits’)
    • This is the highest figure on record and is a 14.5% increase from September 2022
  • Delays to admission stood at 29.8%, this is the highest on record and a 2.8 percentage point decrease from September 2022

The latest beds data for October 2022 show:

  • Last month there were 97,350 general and acute beds available, an increase of 0.71% from September. The occupancy rate was 94.3%, 0.7 percentage points higher than September, the highest monthly figure on record
  • The occupancy rate for adult general and acute beds was 95.6%, also the highest figure on record.

The latest Hospital Episodic Statistics published by NHS Digital for September 2022 show:

  • Patients leaving the department before being seen stood at 5.2%. This is a decrease of 0.2 percentage points from August 2022, but a decrease of 0.7 percentage points from September 2021. 
  • Unplanned reattendance rate was 8.5%. This is 0.4 percentage points lower than September 2022, but 0.3 percentage points higher than September 2021.  
  • Median time in department for admitted patients was 404 minutes. This is an increase of 29% compared with September 2021 (314 minutes). For all patients, the median wait was 192 minutes. 

Emergency Care ‘remains in extreme crisis’

More than one third of patients facing long waits in Scotland, as Emergency Care remains in severe crisis.
Responding to the latest weekly Emergency Department performance figures in Scotland Dr John Thomson, Vice President of The Royal College of Emergency Medicine Scotland, said: “We are continuing to see severely poor performance in the Emergency Care system. Staff are becoming more and more burnt out; the appalling crisis in Emergency Care is seriously distressing.

“The public are extremely worried about these long waiting times, and rightly so, because patients are coming to harm. Staff continue doing all they can to deliver care and keep patients safe, but it is incredibly challenging.

“It is a desperate situation, a result of widespread shortages of staff and beds throughout the system and a crisis in social care. Despite exiting winter and entering spring, the situation remains dire; we have never faced a crisis worse than this. The intense workload is breaking staff, and the distressing circumstances are breaking their morale.

“Patients continue to face seriously long waits, and we continue to state that this crisis is worse than ever, and that patients are coming to harm. The government cannot let this deteriorate further, staff and patients urgently need meaningful action now to tackle the desperate situation in Emergency Care and address the widespread staff shortages, the bed shortages, and the social care crisis.”

The latest weekly Emergency Department performance figures for Scotland show:

There were 22,774 attendances at Emergency Departments

Four-hour performance was 66.2%, the lowest ever on record-

7,705 patients waited more than four-hours in an Emergency Department

More than 3 in ten patients were waiting for more than four hours in an Emergency Department

2,373 patients waited more than eight-hours in an Emergency Department

Nearly one in six patients were waiting for more than eight-hours in an Emergency Department

944 patients waited more than 12-hours in an Emergency Department

One in twenty-five patients were waiting more than 12-hours in an Emergency Department

One in four ambulances delayed 30 minutes or more as Emergency Care falls deeper into crisis

The latest Winter Sitrep data for the week ending 27 March show:

  • There were 79,588 ambulance arrivals, 2.7% less than the previous week.
  • More than one quarter of ambulances experienced delays of 30 minutes or more, equal to 21,051 ambulances – an increase of 7.4% on the previous week
  • This is the highest proportion of ambulance delays on record
  • More than one in nine ambulances were delayed by more than 60 minutes, a 10.2% increase on the previous week, setting a new record high for this reporting period.
  • The average number of delays for this winter has continued to creep up, increasing from 0.3% up to 21.3%. The previous highest weekly average number of delays was 14.3% in 2019-20.

The Royal College of Emergency Medicine and The College of Paramedics have collaborated on this Ambulance Handover Options Appraisal guidance that details the ways in which Paramedics and Emergency Medicine staff can reduce ambulance handover delays.

Dr Ian Higginson, Vice President of The Royal College of Emergency Medicine, said: “The data show Emergency Department crowding, long “hidden” within the walls of EDs, has become more visible as handover delays have dramatically increased, leading to ambulances waiting outside EDs with their patients still inside.

“It is vital that ambulances return to active service whenever possible and safe to do so. Delaying ambulance handovers should be a last resort. Holding patients in ambulances leads to unnecessary delays to their care, leaving seriously ill or injured patients in the community requiring an ambulance to wait longer.

“Ambulance handover delays are almost entirely caused by dangerous crowding in Emergency Departments. The root cause of these problems is “exit block” where there are delays for patients to be admitted to inpatient beds from the ED. Patients suffer harm or die unnecessarily when they cannot get an ambulance in time, when they are held in ambulances on arrival in ED, or when they are treated in crowded EDs.

“Emergency Departments must have sufficient capacity to meet demand, and constant flow from the Emergency Department into inpatient beds, otherwise they will not be able to keep patients and staff safe. This means that risk must be properly shared within organisations, and through systems.

“When this does not happen leadership teams tend to look for mitigation. Unfortunately, this mitigation is usually focused at the front door of the hospital, rather than being directed at the root cause of the problem. The Royal College and The College of Paramedics have produced this joint guidance to support good decision making when managing ambulance handover delays in an effort to tackle ambulance handover delays and dangerous Emergency Department crowding.”

Tracy Nicholls, Chief Executive of The College of Paramedics, said: “We hear from our members how consistently challenging this situation is and, whilst we can see that paramedics, ambulance clinicians and hospital ambulance liaison officers are doing everything they can, the system is now at breaking point. 

“Those who need an ambulance are continuing to wait an unacceptable length of time and those paramedics and ambulance clinicians who are running to their next job can clearly see how long their next patient has been waiting and know they are going to be met with frustration, anxiety or fear.

“It seems incongruous that additional measures are being taken at the front door when the whole system flow of patients still needs to be addressed, but we suspect that there are now few options left without further risk to both those who are using the ambulance services and those who are working within them.

“Ambulance operations centres are still fielding calls at record numbers because callers want to know when an ambulance will arrive and are often calling back time and time again.

“It is difficult to hear that an ambulance might be delayed but imagine how a caller feels when their 999 call isn’t answered straight away. The moral injury is not just with the paramedics, but also with all of those involved directly with patients and their care.

“The College supports RCEM’s call for both the reduction in ambulance handover delays and in ED overcrowding.  It is only by working together as a system that we will see this much-needed change and this guidance document outlines the risks associated with the current challenges.”

Emergency Care faces continued pressure as Scottish Government publishes workforce strategy


The latest weekly update of Emergency Department activity and waiting time statistics show:

  • There were 24,920 attendances, the highest since week ending 10 October 2021
    70.5% of attendances were seen and resulted in subsequent admission, transfer or discharge within four hours
  • 7,347 patients were delayed by four hours or more, this is the third highest on record
    1,825 patients were delayed by eight hours or more
  • 643 patients were delayed by 12 hours or more, this is the second highest on record

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “The data show the stark picture of the health system in Scotland right now and the serious crisis Urgent and Emergency Care is facing.

“There are extremely high numbers of patients being delayed for long periods of time, and we know that these long waits are associated with a high risk of harm or even death.

“This is a critical time. The pandemic is not over. Covid is ever present in the community, with increasing numbers of covid patients in hospital and a high level of covid related staff absences. The workforce is burnt out and overwhelmed, every shift is extremely demanding with staff covering for absent colleagues and managing high numbers of patients, doing their best to keep them safe and minimise harm. The moral injury to our colleagues working in our Emergency Departments cannot be underestimated.

“We welcome The Health and social care: national workforce strategy published last week by the Scottish Government. It is a positive strategy for the next five years. We especially welcome the commitment to grow the NHS workforce by 1,800 WTE staff and increase the number of medical school places by 500.

“However, we are disappointed both not to have been consulted on this strategy and by the limited mentions of Urgent and Emergency Care. We look forward to the Cabinet Secretary for Health and Social Care consulting with The Royal College on the meaningful details for Emergency Medicine including staffing and capacity needs.”

RCEM: Current A&E performance trend is ‘extremely worrying’

In October 2021 there were 108,279 attendances to major Emergency Departments across Scotland, the number of attendances dropped by 5,719 patients (5%) compared to the previous month, September 2021.

Despite this, data show that four-hour performance in major departments has once again reached a new record low, with 70.9% of patients being seen, transferred or discharged within four-hours – 2.5 percentage points lower than the previous month, September 2021. 

In October 2021 2,533 patients spent 12-hours or more in a major Emergency Department, this is an increase of 30% compared to the previous month, September 2021, and the highest number on record. 

Data also show that 8,181 patients spent eight hours or more in a major Emergency Department. This is an increase of 21% compared to the previous month, September 2021 and is also the highest number on record. 

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “Yet again we are reporting on the worst performance figures on record. 1 in 13 patients are now delayed by eight hours are more.

“This trend is extremely worrying and, most of all, dangerous for patients. Each month, the number of patients that have come to avoidable harm grows. So far in 2021, 387 excess deaths have occurred as a direct result of crowding. 

“This number will continue to increase unless patient flow is prioritised this winter; this means freeing up beds where possible by ensuring that patients have timely access to social care, utilising the Discharge to Assess model, and avoiding admission when appropriate by maximising the use of Same Day Emergency Care. 

“Every winter we know that the increase in demand for unscheduled care, and therefore beds, disrupts elective surgery – this is not a new phenomenon by any means. 

“However, with a record number of patients awaiting surgery, ensuring that unscheduled care does not derail progress on the backlog is more crucial than ever. This requires a whole system approach and cannot be tackled in isolation. If poor patient flow in emergency departments is addressed successfully, this will go some way in mitigating the risk of further disrupting elective care. 

“We are very keen to work with the Scottish government on what can be done in the short term to alleviate the immense pressures EDs are currently facing.

“Accompanying this, we continue to call on the Scottish government to set out a long-term workforce plan. The required expansion in capacity cannot be safely achieved without both recruiting new and retaining existing staff.

“At present we need an additional 130 EM consultants along with sufficient numbers of both junior and supporting staff and nurses.”