Intended for healthcare professionals


Emergency department pressures need to be tackled through integrated urgent and emergency care

BMJ 2015; 350 doi: (Published 20 January 2015) Cite this as: BMJ 2015;350:h322
  1. Chris Ham, chief executive
  1. 1King’s Fund, London, UK
  1. c.ham{at}

Politicians must look for evidence based solutions and avoid the NHS becoming a political football

If, as the saying goes, a picture paints a thousand words, then the photograph of a tent being erected outside Great Western Hospital in Swindon to care for patients spilling over from the emergency department spoke volumes. The similarities with battlefield medicine were both obvious and appropriate at a time when hard pressed staff must feel they are in a war zone.

The failure of the NHS in England to meet the four hour target for treatment in emergency departments, and for performance on this indicator in the last three months of 2014 to have fallen to its lowest level since 2003, is worrying for patients and for politicians. Although more than 90% of patients overall, and more than 80% of patients in major emergency departments, were still seen and treated within four hours, pressures at the front door of hospitals signify a health and social care system near breaking point.

While the presenting problem is emergency care, the causes include growing numbers of patients waiting to be discharged, hospitals running out of beds, difficulties for some patients in getting a timely appointment with a general practitioner, and insufficient community services to help avoid admissions and to support people returning home from hospital.

Pressures in emergency departments and rising emergency admissions are also leading to more planned admissions being cancelled, often at short notice, to release beds and staff to deal with these pressures. This will make it almost impossible for the NHS to maintain short waiting times for patients with suspected cancer and the 18 week referral to treatment target for diagnostic tests and elective procedures. With increasing numbers of patients being cared for on trolleys in corridors, the spectre of an NHS in crisis has returned to haunt health ministers, especially as the prime minister made a categorical commitment to maintain short waiting time targets in 2011.1

Knock-on effects from social care

The government is correct to argue that it started planning for winter pressures early and has provided additional funding this year to enable the NHS to cope. It is much more vulnerable to the criticism that cuts in social care are one of the factors behind delays in discharging patients from hospitals because of the increasing difficulties in arranging council funded support in people’s homes. Since 2010, spending on adult social care has fallen by 12% in real terms, with the result that one quarter fewer people are receiving council funded services.2

Questions have also been raised about the effectiveness of the telephone helpline, NHS 111, established to replace NHS Direct and where the lack of clinical experience of staff answering calls may be a factor in more patients being advised to attend hospitals.

Even more important is the lack of integration of NHS 111 with other parts of the urgent and emergency care system, the fragmentation of which has been identified by NHS England’s chief executive, Simon Stevens, as a fundamental weakness that needs to be addressed.3 The answer to the problems facing the NHS lies in much greater integration of care both within the NHS and between the NHS and social care, as the Keogh review recommended in 2013.4

New ways of working

Greater integration means more investment in community nursing, social care, and GP services. It also means hospitals changing the way they treat patients—for example, by moving rapidly to seven day working and ensuring that specialists’ expertise is available at the front door of hospitals. This expertise must focus on care of frail older people, who account for much of the increase in demand for care and among whom mental health needs are increasingly important. Joining up care for older people through adopting known best practice would do much to relieve the pressures on the NHS.5

Several NHS hospitals are already doing this by involving psychiatrists, geriatricians, and their teams in emergency departments. Some of these hospitals also employ GPs to treat patients who turn up with minor conditions, releasing specialist staff to care for those with more serious and urgent needs. Tackling the pressures in emergency departments also hinges on improving flow within hospitals through improved discharge and better integration between staff working in hospitals and their colleagues in the community.6

All three of the main political parties have nailed their flags to the mast of integrated care, but it will be a huge challenge to deliver given the current fragmented and confusing arrangements. There is therefore every prospect that NHS pressures will get worse before they get better, especially when the latest data on NHS performance in England reports not just declining performance on key indicators but also increasing pessimism on the part of finance directors about the future.7

Longer waiting times for emergency and other care mean that the NHS is back in the headlines for all the wrong reasons. An important concern to the public has become even more salient with the general election less than four months away. Now more than ever politicians need to focus on finding solutions based on evidence of what works, recognising that there is no quick fix even in an election year, and avoiding the NHS becoming a political football.


Cite this as: BMJ 2015;350:h322


  • Competing interests: I have read and understood BMJ 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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