Intended for healthcare professionals

Feature Data Briefing

Are accident and emergency attendances increasing?

BMJ 2013; 346 doi: (Published 07 June 2013) Cite this as: BMJ 2013;346:f3677
  1. John Appleby, chief economist
  1. 1King’s Fund, London, UK
  1. j.appleby{at}

John Appleby unpicks the claims made for the causes of rising waiting times in emergency departments

A rise in the proportion of patients waiting over four hours in accident and emergency departments in England—the highest quarterly figure since 2003-04 (fig 1)—has prompted a list of reasons for this recent breach of the government’s target.1 Health secretary Jeremy Hunt has principally blamed lengthening waiting times on changes in general practitioners’ out of hours arrangements in 2003-04 and general difficulties for patients in obtaining speedy appointments with their GPs.2 Conservative MP Chris Skidmore suggested problems were down to changing population demographics—including immigrants’ use of emergency departments in place of general practice.3 On this, evidence suggests recent immigrants’ use of secondary care services is actually less than might be expected.4 An obvious reason for recent problems, however, is that demand is rising. But is it?


Fig 1 Proportion of patients waiting more than four hours in emergency departments from arrival to admission, transfer, or discharge5

As figure 2 also shows, in 2003-04—when the large increase in attendances started—there was a change in the data series. Until 2003-04, statistics on emergency department attendances included “major” units only. But around this time more, smaller units—including walk-in centres and minor injuries units—were introduced and the statistical collection was changed to record attendances separately for “type 1, 2, and 3” units. Type 1 essentially reflecting major units and types 2 and 3 defined as “specialist departments” and “other A&E and minor injuries units” respectively (the latter including walk-in centres).


Fig 2 Annual attendances in English emergency departments, 1987-88 to 2012-136 7

So, much of the increase in 2003-04 was due to previously unrecorded attendances being collected as well as additional—but less serious—work being carried out in the new units. From 2003-04 to 2012-13, attendances in type 1 units have remained more or less unchanged. It is admissions to type 2 and 3 units that account for the bulk of the increase in attendances.

While the NHS has experienced a huge increase in accident and emergency workload over the past decade, over the past 30 months this increase has started to level off. Figure 3, for example, shows weekly attendances between November 2010 and May 2013. The trend increase over the whole period works out at about 1.9% a year—an increase, but not huge.


Fig 3 Proportion of patients waiting longer than four hours in emergency departments: weekly data, November 2010 to May 20135

Of course, even relatively small rises in attendances can cause problems for those emergency departments near to or at capacity. Couple this with other problems —such as pressure on beds in other parts of the hospital—then delays in transferring those patients in emergency departments who need further treatment and for others in emergency departments can be exacerbated.

Meanwhile, as figure 4 shows, the more up to date weekly data on the proportion of patients waiting more than four hours show a fall in the first few weeks of May—partly because of the usual seasonal trend (although a bit later this year) and a greater focus by hospitals and NHS England on dealing with the problem as the waiting times escalated.8 So, problem solved? Let’s see what happens next winter and the outcome of NHS England’s review of the urgent care system—due to report this September.9


Fig 4 Weekly attendances in English emergency departments, 7 November 2010 to 26 May 20136


Cite this as: BMJ 2013;346:f3677


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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