On 20 July 2023, the House of Lords is due to debate the following motion:

Baroness Armstrong of Hill Top (Labour) to move that this House takes note of the report from the Public Services Committee ‘Emergency healthcare: A national emergency’ (2nd Report, HL Paper 130).

1. Background: The committee’s inquiry

The NHS describes emergency care as involving life-threatening illnesses or accidents which require immediate treatment from the ambulance service (via 999) and an emergency department (A&E).

In September 2022, the House of Lords Public Services Committee launched an inquiry to investigate the barriers to accessing emergency services. It explained it would explore how services “can be organised to ensure that the welfare of service-users is always at the forefront of decision making”. To do so, the committee said that it would “look at processes organising these services at the local and national levels, and how priorities and targets are set”. It also said that it would consider how creative practices could be rolled out to improve services and how enhanced collaboration between police, fire and rescue, and emergency healthcare services could provide better outcomes for patients.

The committee received both oral and written evidence from a variety of individuals and organisations, some of which was anonymised and related to experiences of frontline work. Copies of the evidence received can be found on the committee’s website. In addition, the committee held both a private seminar and an online engagement event with front-line emergency staff and some senior leadership.

2. “A national emergency”: Committee findings and recommendations

The committee published its report, ‘Emergency healthcare: A national emergency’, on 19 January 2023. It found that “emergency access to healthcare is in crisis” and that the problem had been created by unmet need at every level of the health and care services. The committee also argued there was “no sign” of an “adequate plan or the necessary leadership” to address the problems.

2.1 Summary of findings

Summarising its findings, the committee said that unmet need in primary and community care, as well as low capacity in hospitals and social care, has “left emergency health services gridlocked and overwhelmed”. It argued that patients waiting for care experienced distress and lengthy delays, with the situation also leading to “substantial clinical risk” for patients.

On the causes of these delays, the committee explained that patients are struggling to access care in the community and therefore turn to emergency services by attending A&E or calling an ambulance. As hospitals are “overcrowded and under-staffed”, these ambulances can get stuck outside waiting to hand over patients and unable to respond to further calls. The committee reported that inside A&Es, there are substantial delays for patients before they are treated or admitted.

At the other end of the patient journey, when they are ready for discharge, there are often waits for community or social care to become available. This means beds cannot be accessed by other patients. The committee said that while many patients will only experience one delay, for some “the process is a long waiting game at each stage”. Looking forward, the committee argued that demographic change means that the problem will get worse.

The committee was critical of the data published on waiting times and argued that the number of patients waiting 12 hours or more in A&E is around five times higher than the number most regularly used. It explained that the monthly data published on waiting times which exceed 12 hours “does not reflect the patient experience” as the clock is started when a clinician decides to admit a patient, not when the patient entered A&E. The committee argued that this was “a fundamentally dishonest way of reporting data”. To demonstrate the problem, the committee said that in August 2022, 133,286 people waited in A&E for over 12 hours. Of these, over 100,000 were not reflected in the monthly data.

Arguing that the scale of the challenge to address the issues in emergency healthcare is substantial, the committee called for decision makers to work together and provide the system with the necessary resources. The committee explained that this meant giving cross-government attention to the problem, with accountability “from the prime minister down”.

Within the report, the committee also argued that the emergency health workforce faces significant challenges, including shortages, low job satisfaction and retention rates, as well as poor health. For example, it said that ambulance staff had been described as “overwhelmed” and “fatigued and depleted”, and highlighted that the ambulance service had a vacancy rate of 6%. The committee warned that without “concerted effort”, many staff could leave the health service.

The committee also noted its last report, ‘Fit for the future? Rethinking the public services workforce’, highlighted substantial staff shortages across the public sector. The committee explained that this report had found that efforts to address staffing issues were “at far too small a scale” and said that their second inquiry “reaffirmed those findings”.

2.2 Recommendations and action plan

The committee made a number of conclusions and recommendations in its report. It explained that these recommendations applied primarily to England; however, it said that those on policing in particular were also relevant to Wales.

Within its report, the committee published an action plan which it said encompassed its recommendations. It explained that the plan set out how government could address some immediate challenges in the short term and begin developing a new model for emergency health services which are fit for purpose in the long term. The plan set out the following recommendations:

  • An emergency response: Refer the crisis in emergency health services to a Civil Contingencies Committee (COBR).
  • Deliver care in the right place at the right time: In the short term, boost the number of clinicians in 999 and 111 services so that patients are being directed to the right services at the right time.
  • Unlock the gridlock: Incentivise faster safe discharges from hospitals and increase capacity in hospitals and social care to make sure people can move through the health system and do not end up stuck in ambulances or at A&E.
  • Understand the problem: Change performance data so it accurately reports the true waiting times experienced by patients so that decision makers have a clear picture of the problem and the public can hold them to account.
  • Address unmet need: Boost capacity in hospitals and social care. Make it easier for patients to get care in the community both before they reach crisis points (preventing admissions) and following discharge.
  • A new model for emergency health services: Develop a new model for emergency health services which recognises the current crisis, the type of demand services face and clinical best practice and, for accountability purposes, sets out appropriate performance measures.

Commenting on the findings, the committee’s chair, Baroness Armstrong, said that increased pressures across the health and social care sector are not new, especially during winter, and that the committee had been aware of this when starting its inquiry. However, Baroness Armstrong argued that the committee “could not have envisaged the extent and the severity of the current crisis, which some estimates suggest is causing 500 additional deaths per week”.

Looking forward, Baroness Armstrong said that the problems had been widely discussed and called for a new approach to be taken. She argued that the government should treat “this crisis with the urgency it deserves and address it as a national emergency”. A referral for consideration by a COBR committee was described as “the only appropriate way to begin to remedy the crises”.

3. Government response

3.1 Response to the committee’s action plan

The government responded to the committee’s report on 24 March 2023. As part of this, it set out the following responses to the recommendations highlighted in the committee’s action plan:

  • The government said that it did not agree with the committee’s recommendations to refer the issues with emergency healthcare to a COBR committee. It argued that the Department of Health and Social Care and NHS England have “established functions to tackle issues within the health system, including demand pressures, and [are] taking action on urgent and emergency care”.
  • On the call for more clinicians in 999 and 111 services, the government said it was looking to better use clinicians in 111 for the patients who will benefit most and, to support this, it needed to grow the workforce. The government said that from April 2023 it would launch a promotion campaign for working in NHS 111 and integrated urgent care as a flexible option for clinicians, including returners. It also said that it would provide a route for retiring or recently retired clinical staff to work in NHS 111.
  • Responding to the recommendation that it should incentivise discharges at the right time for patients to free up hospital capacity, the government said that it agreed with the importance of safe and timely discharges to the appropriate setting. It detailed actions it had taken to improve delayed discharges. For example, it said it had provided £700mn of funding this winter. The government also highlighted funding it was making available in the next few years, saying it had allocated £2.8bn in 2023–24 and up to £4.7bn in 2024–25 in additional funding to support adult social care and discharge. Other actions noted included the introduction of transfer of care hubs ahead of winter 2024 and the creation of the national health and social care discharge taskforce in January 2022.
  • On the call for A&E waiting times data to reflect the true patient experience, the government said that it would publish data on 12-hour delays from time of arrival in A&E from April 2023.
  • For the recommendation that capacity is boosted in hospitals and social care, the government outlined information on its work to increase capacity in urgent and emergency care as well as details on its plans to grow the workforce. In addition, it set out information on work to improve staff wellbeing.
  • The committee called for a new model for emergency health services. In response, the government noted its ‘Delivery plan for recovering urgent and emergency care services’, which it published in January 2023. It said that this plan “sets out a vision for the future of urgent and emergency care services nationally”.

3.2 Recovery plan

As highlighted in the government’s response to the committee’s report, on 30 January 2023 the Department of Health and Social Care published a ‘Delivery plan for recovering urgent and emergency care services’ (the recovery plan). Within this plan, the government acknowledged that urgent and emergency services had been through “the most testing time in NHS history with a perfect storm of pressures impacting the whole health and care system but causing the most visible problems at the front door”.

The government said that despite extensive preparations for winter, problems discharging patients to the most appropriate care settings, alongside the demands of flu and Covid-19, had seen hospitals reach record occupancy levels. It explained that this had caused patient ‘flow’ to be slower. For example, it highlighted that patients had spent longer in A&E and had waited longer for ambulances. Hospitals were also reported as fuller than before the Covid-19 pandemic, with 19 out of 20 beds occupied and up to 14,000 beds occupied by someone who was clinically ready for discharge. In addition, the number of the most serious ambulance call-outs had increased by a third on pre-pandemic levels. The government said that these pressures had “taken their toll on staff”, who had to work in “an increasingly tough environment”.

However, the government said that the challenge was not only with ambulances or emergency departments, “and so neither are the solutions”. It argued that recovery would require different types of providers working together and joining up care. It explained that this should be led by local systems and backed by additional investment.

To support recovery, the government explained that its plan set out a number of ambitions, including:

  • Patients being seen more quickly in emergency departments. The government aims to achieve 76% of patients being admitted, transferred or discharged within four hours by March 2024, with further improvement in 2024/25.
  • Ambulances getting to patients quicker. The government stated its ambition that ambulance response times for category 2 incidents would decrease to 30 minutes on average over 2023/24, with further improvement in 2024/25.

The government said that these ambitions represented “one of the fastest and longest sustained improvements in emergency waiting times in the NHS’s history”. However, it also argued that the ambitions would not be enough on their own. The government therefore set out five areas its plan would focus on to transform patient care:

  • Increasing capacity: Increasing the size of the workforce and supporting staff to work flexibly for patients.
  • Improving discharge: Working jointly with all system partners to strengthen discharge processes, backed up by more investment in rehabilitation and social care, and with a new metric based on when patients are ready for discharge.
  • Expanding and better joining up health and care outside hospital: Increasing capacity in out-of-hospital care, so that people can be better supported at home for their physical and mental health needs, reducing unnecessary admissions to hospital.
  • Making it easier to access the right care: Ensuring healthcare works more effectively for the public, so people can more easily access the care they need, when they need it.

In addition, the government outlined funding commitments which it argued would support the recovery plan. This included:

  • £1bn of dedicated funding to support capacity in urgent and emergency services
  • £150mn to build 150 new facilities to support mental health urgent and emergency care services
  • £1.6bn of additional social care discharge funding over 2023/24 and 2024/25

3.3 NHS 15-year workforce plan

On 30 June 2023, NHS England published its ‘NHS long term workforce plan’. Prime Minister Rishi Sunak described it as a plan for investment and reform. He also explained that it was developed by the NHS and backed by the government.

Outlining the issues the plan aimed to address, Mr Sunak said that compared with other healthcare systems globally the NHS is “particularly reliant on international recruitment”, with around a quarter of the workforce recruited from overseas. He also noted that the NHS has significant levels of temporary staffing to cover high vacancy rates. In addition, he highlighted that temporary staff supplied by agencies cost an average of 20% more than those from the NHS’s own ‘staff banks’.

To address these issues, Mr Sunak said the government and NHS would take a longer-term strategic approach to workplace planning. He said this would mean training more staff, retaining staff and reforming the way staff work. Mr Sunak also set out some of the actions the plan outlined in these areas. For example, under training more staff, he said “we will fund the largest ever expansion of domestic education and training places”.

4. National Audit Office report

In June 2023, the National Audit Office (NAO) published a value for money report which focused on ‘Access to unplanned or urgent care’. The NAO explained that the report:

[…] gives a factual overview of NHS services that may be used when people need rapid access to urgent, emergency, or other non-routine health services, and whether such services are meeting the performance standards the NHS has told patients they have a right to expect.

The NAO’s report covered general practice, community pharmacy, 111 calls, ambulance services (including 999 calls), urgent treatment centres and A&E departments. It said that in 2021–22, there were close to 500mn patient interactions across these services, with a total estimated annual cost of £21.5bn a year.

The NAO set out a number of key findings relating to demand, NHS capacity and performance. On demand, it found that population changes are contributing to increasing demand for healthcare and that demand for unplanned or urgent care is also growing.

On capacity, the NAO’s findings included that although the number of general and acute hospital beds had increased slightly, occupancy rates had also risen, with patients staying longer in hospital compared with previous years. Focusing on staffing, the NAO said that the number of NHS staff had increased, including those working in unplanned or urgent care. It also reported that the number of staff vacancies across the NHS rose from the start of 2021 but had recently fallen. In addition, it noted that spending on the NHS had continued to increase.

On performance, the NAO’s findings included that:

  • patients’ access to services for unplanned or urgent care has worsened
  • there is considerable variation in service performance and access, both between regions and between different providers
  • Covid-19 had, and continues to have, an adverse impact on the NHS’s capacity to meet healthcare needs
  • the NHS has not met key operational standards for unplanned or urgent care since before the pandemic
  • performance against operational standards, and more widely, has deteriorated further since the onset of the pandemic
  • overall performance of the unplanned and urgent care system has been worsened by delays transferring patients from one service to another
  • the NHS has not been able to secure the full benefits of increased spending and staff numbers and productivity has fallen since the onset of the Covid-19 pandemic
  • NHS England has a plan to reduce waiting times and improve patients’ experiences

In concluding remarks, the NAO said that more people than ever are receiving unplanned and urgent NHS care every day. It also noted that to support these services, “the NHS is spending increasing amounts of public money and employing record numbers of people”. However, the NAO argued that despite this:

[…] patients’ satisfaction and access to services have been worsening, suggesting there is no single, straightforward solution to improving what is a complex and interdependent system. NHS England’s recovery plan for urgent and emergency care aims to improve services by March 2024. The long-term trends in workforce, activity, spending and performance indicate this will be a significant challenge.

Commenting specifically on the government’s January 2023 recovery plan, the NAO said it was too early to assess whether it was working. It argued that how well the NHS copes with winter 2023–24 pressures would be the first indication of whether or not it was succeeding.

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Cover image by Ian Taylor on Unsplash.