“Staff faced increasingly difficult conditions, with huge numbers of patients facing long and dangerous waits throughout the system. We know these long waits are associated with patient harm and even patient deaths, it is increasingly distressing for staff and patients.
“Exit block – where patients are unable to be admitted to a bed because other patients are unable to be discharged – was the worst it has ever been, meaning the entire Emergency Care system has been gridlocked – like a traffic jam.
Patients spending far longer in Emergency Departments than they should be, often in inappropriate or inadequate areas, on trolleys in corridors, in small, cramped spaces with a lack of privacy and lack of dignity.
“We welcome the gravity with which the First Minister and the Cabinet Secretary are taking the current crisis in Emergency Care. We have had constructive meetings with the Cabinet Secretary and do feel that there is recognition of the root of the issues and a political will to tackle it.
“We especially welcome the focus on social care and the whole system capacity. It is critical that we sort out discharges, ensuring patients who are medically fit to leave are able to return home or to the community in a timely way. We must continue to focus on this to free up beds so we can increase flow throughout hospitals and admit patients from Emergency Departments into a bed on wards.
“While these are the right initiatives, the green shoots of hope are not translating to big enough or fast enough improvements. Without significantly increasing capacity across Scotland, we will continue to borrow from tomorrow to cover today.
“This means cancelling elective surgery so we can admit Emergency Care patients to a bed, but at the cost of further delaying what may be serious surgery for patients who have already waited for a long time. We should not be in a position where decisions like these need to be made.
“It is wrong for specialties to compete for beds for their patients. What is better is to increase the number of staffed beds throughout the system, where safely possible, so we do not need to compromise on which patients are able to be treated.”
“We are deeply concerned about this winter; the crisis continues to escalate. Patients continue to face exceptionally dangerous long waits. We estimate that one in 72 patients waiting between eight to 12-hours in an Emergency Department can die as a result of these waiting times (30-day all-cause mortality).
“But these are data, the reality is Emergency Departments are overcrowded and in extremis. Patients with an array of different needs and care are packed in, facing high-risk and uncomfortable waits on trolleys in corridors. There is a lack of privacy, a lack of dignity, staff are stretched thinly meaning patients find it difficult to get the things they need – be it food or water or bathroom facilities, while they wait hours for a bed. Meanwhile, ambulances queue outside our Emergency Departments with more patients waiting to simply get in.
“Emergency Medicine staff and ambulance crews and paramedics are highly skilled, highly trained competent professionals, but the inability to move patients through the system means they are overstretched and overwhelmed, and unable to provide the high-quality care that they are trained to provide. Patients are worried and anxious, staff are increasingly distressed, unable to provide the real care that they want and should be providing.
“The solutions are simple; bolster the social care workforce to ensure the timely discharge of patients; tackle the recruitment and retention crisis among all health workers; increase capacity by opening an additional 1,000 beds in the acute system across Scotland. These will begin to address the root of the crisis.”
Addressing the concern around Strep A and the increase in attendances at Paediatric Emergency Departments in Scotland, Dr JP Loughrey said:“In recent weeks we have seen a marked increase in the number of children attending our Paediatric Emergency Departments, cases of Strep A remain high.
“Emergency Departments remain open to those who need it. If children have symptoms, or parents are unsure, please seek care first through NHS 24, your GP or local pharmacist. If the symptoms are severe or your child’s condition worsens, do not hesitate to seek the necessary emergency care. We are here to help.”
Responding to the latest Emergency Department performance figures for Scotland for September 2022 Dr John-Paul Loughrey, Vice President of the Royal College of Emergency Medicine Scotland, said:“The situation as we enter winter is dire. Month-on-month, more and more patients face longer and longer waits – that we know are associated with patient harm and even death.
“Emergency Medicine staff and our paramedic colleagues are doing all they can to ensure the urgent and emergency care system continues to function and patients continue to receive care. We want to thank health care workers for their hard-work and diligence at this incredibly challenging time.
“We know that patients are deeply worried about the crisis. Emergency Medicine staff are worried too, distressed that they are unable to move patients through the hospital or take in patients from ambulances to the Emergency Departments.
“The difficulty in discharging patients from hospital when they are medically fit to be discharged is causing exit block in hospitals. The lack of social care is preventing these patients from being discharged.
“This is leading to a lack of flow throughout the hospital and leading to long waits in Emergency Departments, long waits in ambulances outside Emergency Departments, and long waits for an ambulance in the community.
“The Scottish Government must get a grip of this crisis and urgently boost the social care workforce, only then will we be able to discharge patients, free up beds and reduce these long waits throughout the system.”
A new report from The Royal College of Emergency Medicine finds that patients presenting with mental health problems are twice as likely to spend 12-hours or more in Emergency Departments than other patients.
National data show that nearly one in eight (12%) mental health patients presenting to an Emergency Department in crisis face a 12-hour stay from time of arrival, compared with nearly one in 16 (6%) of all attendances.
A recent SNAP survey of Emergency Departments found that more than one third of clinical leads reported patient stays of 72 hours or more in the last week, for patients with mental health needs.
‘Mental Health Emergency Care’ is the latest report in our series of explainers looking at the web of issues facing Emergency Departments. The report highlights that while patients with mental health presentations account for a very small proportion of Emergency Department attendances, they spend a disproportionate amount of time waiting for a mental health bed if they need admission.
Often, it is the patients who are most unwell and vulnerable that wait the longest. Those of greatest concern are patients waiting for a mental health bed, patients waiting for an assessment under the Mental Health Act, and Children and Young People presenting in crisis.
The prevalence and complexity of the mental health needs of children and young people increased during the pandemic, while capacity is struggling to meet surging demand.
Half of Emergency Departments in England reported waits of 12 to 24 hours for a child or young person to see a specialist mental health professional, despite the accepted standard for adults being a one hour wait to be seen.
If admission is needed, 46% of Emergency Departments reported that children and young people will wait more than 48 hours for a bed, with two respondents reporting a wait of five days in the Emergency Department.
The report looks in detail at factors contributing to these long waits, such as the reduction in mental health beds, inadequate numbers of children and adolescent mental health professionals, and poor organisation of professionals to assess patients under the Mental Health Act. It also examines the consequences for patients and departments and makes wide reaching recommendations.
Commenting on the findings of the report, Dr Katherine Henderson, President of the Royal College of Emergency Medicine, said: “The system is failing patients who present to Emergency Departments in mental health crisis.
“Those waiting the longest are children and young people, patients waiting for admission to a bed, and patients waiting for assessment under the Mental Health Act. It is unacceptable.
“We know long waits in a busy and crowded environment are harmful for any patient, but for these patients it can cause deep distress and upset and worsen their mental state. We must do more to ensure that these patients are seen, treated, and directed to the right care quicker.
“These patients presenting to Emergency Departments are extremely vulnerable, they are in crisis and seeking Emergency Care, yet are left waiting for hours and even days, before being treated and admitted.”
The explainer also shows that the UK has only 37 psychiatric beds per 100,000 population – far lower than the OECD average of 71 psychiatric beds per 100,000 population – and that since 1987, over 48,000 NHS mental health beds have been cut in England, with 5,000 mental health beds having been cut since 2011 alone.
Dr Henderson said: “Data show that bed occupancy at mental health trusts averaged nearly 90% between 2017-20, 5 percentage points higher than the recommended 85%. The NHS mental health bed numbers are clear; capacity does not meet demand.
“While the move towards a provision of community mental health care has been positive, the cuts to emergency mental health care beds have been devastating. Now, the most vulnerable and desperate patients are truly suffering.
“We urgently need to see an increase in mental health bed capacity, so we are able to admit these patients to a bed and provide the care they urgently need. We regularly hear heart-breaking stories of young people being admitted a long way from their home and family.
“We urge the new Prime Minister and new Health Secretary to prioritise Mental Health care provision in Emergency Departments, especially ahead of winter.
“We are failing these patients and they are suffering; our report and supporting survey show the extent of this crisis. We need urgent action now. To ensure we are able to quickly and effectively help vulnerable patients in crisis the government must increase mental health bed capacity in Trusts.
“Capacity for Children and Adolescent Mental Health Services (CAMHS) is especially important, and CAMHs should be expanded to 24/7 so that children and young people can be assessed and triaged whenever they present at Emergency Departments, rather than face long waits for these services to open.”
“These are the second worst data on record. Too many patients are waiting too long. We know long waits contribute to patient harm. In August over 29,000 patients waited over 12 hours after a decision to admit was made, with some patients waiting up to three days for a bed.
“We think the consequence of this is shown in the ONS data as 500 excess deaths a week. We must not accept these long stays as normal. We need to see leadership and meaningful action that gets to grips with this crisis.
“We urge the new Prime Minister, Liz Truss, and incoming Health and Social Care Secretary, Therese Coffey (above), to make tackling the crisis in Emergency Care a priority.
The scale of patient harm occurring is shocking. The Emergency Care system is failing to its core functions; it is vital that we mitigate the impact of this crisis ahead of winter and do all we can to keep patients safe and reduce these dangerous waiting times.
“The Prime Minister and Health Secretary must urgently bolster the social care workforce. Thousands of beds are occupied by patients who are medically fit to be discharged, but the lack of social care service means that getting patients home is a slow and complex process.
“This means that hospitals have difficulty in discharging patients in a timely way, leading to exit block, poor flow throughout the hospital and subsequent problems in Emergency Departments and ambulance waits. The need for investment in social care couldn’t be clearer.
“Staff are exhausted, overwhelmed and in the midst of the worst crisis the NHS has ever faced. Widespread shortfalls of staff across all grades and departments mean health care workers are spread increasingly thinly and more prone to burnout – there are currently around 130,000 vacancies in the NHS almost 10% of its workforce.
“The Prime Minister must deliver the fully funded long-term NHS workforce plan that the government pledged to deliver in 2019. Emergency Care is in crisis and there is a shortfall of 2,000-2,500 Emergency Medicine consultants and widespread shortages of vital nursing staff, trainees, SAS doctors and junior and supporting staff are contributing to the challenges.”
There were 1,304,378 attendances at major Emergency Departments
There were 1,988,779 total attendances at all Emergency Care facilities
28,756 patients were delayed for 12 hours or more from decision to admit to admission
This is the second highest number of 12-hour waits on record, just 561 short of the previous record in July 2022
There have now been 178,770 12-hour waits (from decision to admit to admission) so far this year
Four-hour performance at major Emergency Departments was 58.0%, this is the second worst four-hour performance on record, the lowest was recorded the previous month, July 2022
More than 2 in 5 patients were delayed by four-hours or more
Type 1 admissions stood at 350,618 (a daily average of 11,310)
130,528patients spent more than four hours in an Emergency Department from decision to admit to admission (also referred to as ‘trolley waits’)
Bed occupancy stood at 92.8% (far higher than the recommended 85%)
‘this should ring alarm bells to all political and health leaders’ RCEM says
Responding to the latest Emergency Department performance figures for Scotland, Dr John-Paul Loughrey, Vice Chair of the Royal College of Emergency Medicine Scotland, said:“The latest Emergency Department performance figures for July should ring alarm bells to all political and health leaders.
“These are the worst performance figures since records began, with over 4,000 patients waiting 12-hours or more in major Emergency Departments in Scotland – equal to nearly one in every 25 patients.
“The depth and scale of this crisis is deeply concerning. Patients are already coming to harm, a consequence of long and dangerous waiting times. These data must be a call to action, especially as winter is fast approaching.
“The government must urgently expand capacity where safely possible; we know there is a shortfall of 1,000 beds in the health system in Scotland. The Scottish government and local authorities must also bolster the social care workforce. Good social care underpins an effective health service.
“Ensuring the timely discharge of patients, which relies on good social care, is crucial for freeing up beds, admitting patients and encouraging flow throughout the hospital.
“Lastly, we must see a long-term workforce plan for the NHS in Scotland. Staff have been pushed to the brink; burnout and distress are leading to health workers considering leaving the workforce.
“We must do all we can to retain staff as well as look to recruiting new staff into the health service. Without the workforce, more and more patients will face longer and longer waits and come to further harm.
“Our priority is patient safety and delivering effective care, that is only possible with a workforce that is not overwhelmed, not burnt out and not undervalued.”
“There were nearly 30,000 12-hour waits (measured from decision to admit to admission) in July 2022, that is more than 3.5 times the total number of 12-hour waits for the whole of 2019.
“This is only the Tip of the Iceberg as the true number of 12-hour waits, measured from time of arrival, is much higher. We urgently need transparency for the scale of the crisis, only then will everyone recognise the reality of the situation and begin to take critical action. We urge NHS England to commit to publishing this data (which is already collected by all Trusts) monthly with immediate effect.
“The crisis is escalating quickly, and health workers are seriously concerned about the quality of care being provided, especially as we exit summer and head into winter. The system is struggling to perform its central function: to deliver care safely and effectively.
“This is a whole-system problem and requires a whole-system approach. There must be total focus on promoting flow throughout the hospital and priority around our ability to provide an NHS that helps patients in an emergency.
“We must ensure patients are discharged in a timely way, so beds are freed and patients in A&Es are able to move through the system and be treated. Flow and discharge rely heavily on an effective social care service that has sufficient workforce – the government must get to grips with this.
“Across the UK we urgently need 13,000 beds to drive meaningful improvement: in Emergency Medicine in England there is a shortfall of 2,000-2,500 Consultants as well as widespread shortages of nurses, trainees, SAS doctors and junior and supporting staff.
“The social care workforce must also be bolstered, which can be achieved by giving these core workers a fair wage that respects and recognises the value of their role. Retention of all health and social care workers is vital, staff are burned out and exhausted, and some are considering their careers.
“We are seeing the sharp demise of the health service and we are seeing little to no political will to act on or acknowledge the crisis – neither of the leadership candidates seem to recognise the scale of the crisis at hand.
“Winter is looming, which will bring a wave of flu and covid and increased footfall in Emergency Departments, with the data as dire as it is today and the scale of patient harm already occurring, we dread to think how much worse things could get for patients.
In winter four-hour performance typically decreases while the number of 12-hour waits significantly increases. We may reach a point where only half of patients are seen or treated within four-hours and see an even higher number of 12-hour waits.”
There were 1,385,080 attendances at major Emergency Departments
There were 2,163,779 total attendances at all Emergency Care facilities
29,317 patients were delayed for 12 hours or more from decision to admit to admission, this is just over 3.5 times higher than the total number of 12-hour waits over the whole of 2019
This is the highest number of 12-hour waits on record
This is a one third increase compared to the previous month, June 2022, or an increase of over 7,000 12-hour waits
There have now been 150,014 12-hour waits (from decision to admit to admission) so far this year
Four-hour performance at major Emergency Departments was 57.0%, this is the worst four-hour performance on record
More than 2 in 5 patients were delayed by four-hours or more
Type 1 admissions stood at 358,284 (a daily average of 11,575
136,221patients spent more than four hours in an Emergency Department from decision to admit to admission (also referred to as ‘trolley waits’)
Over 1,000 patients faced a 12-hour wait in A&E every day in 2021
A new report by The Royal College of Emergency Medicine ‘Tip of the Iceberg: 12-Hour Stays in the Emergency Department’ reveals that on average 1,047 patients waited 12-hours or more from their time of arrival every day in a major Emergency Department in 2021 in England, equalling a total of 381,991 patients experiencing these 12-hour waits in 2021.
There is a total of 124 NHS Trusts in England. The College received responses from 74 NHS Trusts that were contacted. The figures above are only representative of 60% of NHS Trusts in England. The true total figure of 12-hour waits from time of arrival in major Emergency Departments in England in 2021 will be even higher.
These figures show the deep crisis facing the NHS and the Urgent and Emergency Care system. The alarming number of 12-hour waits are an indicator of the serious and dangerous levels of crowding occurring in Emergency Departments.
Crowding is unsafe, inhumane, and undignified for patients, our previous report Crowding and its Consequencesfound that patients can come to associated harm and even death.
The NHS in England currently measures 12-hour waits from decision to admit (DTA). The Decision to Admit is the decision to admit a patient to a hospital bed made by a clinician. Measuring from decision to admit is a gross underrepresentation of the reality of patient waits, as many patients will have already waited for a long period in a busy Emergency Department before this decision is made.
12-hour DTA waits have been increasing substantially, so much so that in the first four months of 2022 alone (January – April 2022) there were a total of 79,610 12-hour DTA waits; nearly as many as the cumulative total of the 11 years since data collection began (82,746 12-hour DTA waits between August 2010 – December 2021). It is evident that while the pandemic has contributed to the current situation somewhat, long waiting times have clearly been rising for over a decade.
Our recent report Beds in the NHS found that 25,000 staffed beds have been lost since 2010/11 and this has contributed to the steady increase in long waiting times in Emergency Departments since 2010/11 as detailed in Tip of the Iceberg.
Commenting on the FOI findings, Dr Adrian Boyle, Vice President of The Royal College of Emergency Medicine, said:“These figures are staggering and show the critical state of the Urgent and Emergency Care system.
“They also make clear that measuring 12-hour waits from decision to admit masks the reality facing patients and staff. Clearly, it is misleading to measure 12-hour waits in this way, and it is detrimental to staff efforts to improve A&E waiting times.
“NHS England have previously promised to make 12-hour data measured from time of arrival in the Emergency Department public and publish it alongside monthly NHS performance figures. We are still waiting for them to fulfil their promise.
“We recently wrote to Amanda Pritchard, Chief Executive of NHS England, about this, questioning why the data has not yet been published and when it will be. We have not received a response. Until it is published the NHS cannot hope to drive meaningful change and improvement in Emergency Care. Publishing this data will bring about greater accountability, and help all stakeholders understand the extent of crowding, long stays, and corridor care.
“NHS England must publish 12-hour data from time of arrival as a matter of urgency, this is the first step towards meaningfully tackling this crisis. At present, we fear that the full scale of this crisis is either being ignored or inadvertently misunderstood by the government.
“To truly tackle the problem, you must understand the scale of the task at hand. This data should facilitate better understanding of the challenges facing Urgent and Emergency Care and the wider health system and allow us to take the steps towards tackling it.
“In the short-term, the government must set out a meaningful plan for social care that includes recruitment and investment in the social care workforce and paying a wage that values and reflects significance of their role.
“In the medium-term, the government must finally commit to publishing a fully funded long-term workforce plan that recruits new staff into the health service and includes measures to retain existing staff who are burned out and questioning their careers. Then will it be possible to open the 13,000 staffed beds required to drive meaningful improvement within the health service.
“The health service is failing, and failure to act will take it deeper into crisis and inevitably lead to another ‘worst winter on record’ and further patient harm. The government can talk about phantom new hospitals all it likes, but political unwillingness to tackle the deepest health crisis in NHS history costs; the cost is both deteriorating patient health and patient lives, and an undervalued workforce struggling to deliver.”
Of 25,000 beds taken out of active service across the UK since 2010, 4,227 have been lost in Scotland
A new report by The Royal College of Emergency Medicine ‘Beds in the NHS’ shows that 13,000 staffed beds are required in the NHS across the UK to drive meaningful change and improvement.
Meaningful change and improvement would constitute a significant improvement in A&E waiting times, ambulance response times, ambulance handover delays, and a return to safe bed occupancy levels.
The report details that since 2010/2011 the NHS has lost almost 25,000 beds across the United Kingdom, and since then the health service and its staff have faced accumulating pressures resulting in a sharp increase in long-waiting times, ambulance handover delays, delayed ambulance response times, cancelled elective care operations, and unsafe bed occupancy levels. This has also had severe consequences on mental health care provision.
The College has stated that the current crisis is both a patient safety crisis and a workforce crisis. The fall in bed numbers and deteriorating metrics have a real terms impact on patient care. The health service is not functioning as it should, the challenging circumstances mean that staff are unable to provide the quick and effective high-quality care they are trained to provide. Patients are distressed by long-waiting times, as are staff who face increasing levels of burnout, exhaustion, and moral injury.
Dr Adrian Boyle, Vice President of The Royal College of Emergency Medicine, said:
“The Urgent and Emergency Care system is in crisis. The situation is dire and demands meaningful action. Ultimately, there are widespread staffing shortages leading to a shortage of staffed beds in the system. Our latest report “Beds in the NHS” shows that 13,000 staffed beds are required in the NHS across the UK to drive actual change and meaningful improvement.
“Since 2010/11 the NHS has lost 25,000 beds across the UK, as a result bed occupancy has risen, ambulance response times have risen, A&E waiting times have increased, cancelled elective care operations have increased. All evidenced by the fall in four-hour performance, the increase in 12 hour waits, the increase in delayed ambulance response times and rise in ambulance handover delays.
“In April 2022 in England, 24,000 patients were delayed by 12 hours or more (from decision to admit to admission), in April in Scotland, 4,000 patients faced a 12 hour wait (from time of arrival), in Wales, 11,000 patients faced a 12 hour wait (from time of arrival), and in March 2022 in Northern Ireland, 8,581 patients faced a 12 hour wait (from time of arrival).
“These numbers are grim; they should shock all health and political leaders. These numbers translate to real patient harm and a serious patient safety crisis. The health service is not functioning as it should and the UK government must take the steps to prevent further deterioration in performance and drive meaningful improvement, especially ahead of next winter.”
“The data show 24,000 patients were delayed in an Emergency Department for 12-hours or more (from decision to admit to admission). This is a staggering and grim number and should seriously alarm all political and health leaders. Patients are coming to harm; now is the time for an Urgent and Emergency Care plan to tackle this crisis.
“The situation is more serious than it has ever been. Patients face long waits for an ambulance, long waits in an ambulance outside an Emergency Department, and long waits in the Emergency Department. These long waits delay care and treatment to patients who may be in a critical condition, and they prevent our highly skilled paramedics from returning to the community and responding to urgent and emergency calls.
“At the heart of the issue are reduced bed capacity in hospitals mixed with an increase in the number long-stay patients – social care patients who do not have sufficient support to return home or to the community – and widespread workforce shortages throughout the system.
“To tackle the crisis the government must publish a fully funded workforce plan that includes measures to retain existing staff, and open 10,000 more beds across the UK.”
Responding to the government’s announcement of more funding for nursing in care homes, Dr Henderson continued:“This announcement is welcome. Social Care nurses have long been undervalued and under-acknowledged. This increase in pay is a welcome step towards showing them the appreciation and gratitude they highly deserve.
“However, it is a shame to see that this increase in funding is limited to NHS-funded nursing care. The entire social care workforce deserves the same acknowledgement and reward. It is critical that during this crisis we attract and retain social care workers and value their time and effort by paying a wage that reflects the significance of their role.
“Good social care supports an efficient health service. Good social care can help prevent A&E attendances. Good social care will support patients moving in and out of hospital in a timely way. Crucially, good social care frees up space for other patients and increases flow throughout the hospital.”
