Intended for healthcare professionals


Recognising how big a problem we currently have in the NHS is the beginning of trying to solve it

BMJ 2022; 376 doi: (Published 14 January 2022) Cite this as: BMJ 2022;376:o103
  1. Katherine Henderson, president1
  1. 1Royal College of Emergency Medicine

We all depend on having a functional emergency system available when we need it most, writes Katherine Henderson

There has been a lot of discussion about whether the NHS will be overwhelmed this winter, if it is already overwhelmed, or if it is just having yet another “normal” winter crisis and will get through, as it always has, despite the additional pressures from omicron. The sight of the army being deployed in hospitals and ambulance services should be a clue that all is not well, but we are on a “war footing” after all.

Can we be more precise about our current state? Is the healthcare system delivering the needed level of patient care? The problem of the elective backlog—known and unknown—is well documented. Individual patients have lost months, or even years of good health. They have anxiety, pain, and debilities that limit their ability to engage fully with their families and society. But how about the ability of the NHS to provide safe and effective emergency care to the most seriously ill, distressed, or injured—the emergency part of the urgent and emergency care pathway? What service should we be delivering, and how do we match up to those standards at the moment?

An emergency care system is designed to provide high quality timely care to those in need of emergency interventions. The World Health Organisation (WHO) recognises that “many proven health interventions are time dependent and that emergency care is an integrated platform for delivering accessible, quality, and time sensitive healthcare services for acute illness and injury,” and that “timeliness is an essential component of quality.”1

Timeliness is defined within the NHS. The current ambulance response goals are: eight minutes for Category 1 (life threatening) incidents and 18 minutes for Category 2 (emergency) incidents such as strokes. In November 2021, the mean average response time in England for Category C1 was 9:10 minutes. For C2, the average response time was 46:37 minutes.2

The nationally defined target for hospitals included in the NHS Standard Contract states that all handovers between ambulance and A&E must take place within 15 minutes, with none waiting more than 30 minutes. In the NHS Winter SitRep analysis for the week 27 December to 2 January, 23% of ambulances were delayed by at least 30 minutes and almost 10% were delayed by at least an hour.3

What this means is we are falling far short of the expectation which the public reasonably have, that in the event of serious illness or injury they will receive timely care in the prehospital environment and that they will get into the emergency department quickly when they get there. During the recent public consultation on urgent and emergency care, the response time for ambulances was rated as important or extremely important by 92% of respondents and 15 minute handovers were rated as important or extremely important by 85%.4 There are good clinical reasons for getting paramedics to patients quickly and ambulance off load standards are important to free up the team to go back out to the next patient. Clinical need and what the public want is well aligned, and we are failing to deliver. There have been concerning ambulance delays in other winters, but not on a scale similar to what we have seen in recent weeks.

Once inside the emergency department there are further metrics which apply to the patient’s journey. The best known is the four hour access standard—a maximum four hour wait in A&E from arrival to admission transfer or discharge. This metric is an NHS constitutional pledge and until a different performance regime is agreed and implemented, it is the standard we should be expecting of the system. The threshold for the four hour standard is set at 95% of patients. Current four hour performance is around 62% in England, and even in Scotland who have traditionally performed better, it is less than 75%. The standard of 95% has not been met since 2015, but in the last year performance has got worse and worse and no one seems to be paying any attention to this. The delays in the emergency department are being treated as a problem of the pandemic when what has really happened is that systemic issues that had led to the deterioration between 2015 and 2019 have simply become more obvious. What is more heart breaking is the disconnect between what anyone would want for their own relative and what happens to the most vulnerable of patients. This is not just about long waits for patients with a broken finger or minor illness. The patients who have been most adversely affected are those waiting for hospital admission. There has been a huge rise in those staying for over 12 hours (NHS England persists in publishing Decision to Admit plus 12 hours despite collecting the data from arrival, but even so the November figures of 10 600 was a new record).5

The underlying bed capacity and workforce problems are clear for everyone to see. There are no quick solutions, but ambulance delays and long waits in emergency departments have consequences for morbidity and mortality, just as delayed cancer surgery or heart surgery have consequences. Recognising how big a problem we currently have in the NHS is the beginning of trying to solve it. We all depend on having a functional emergency system available when we need it most. The issue is not whether the NHS is “overwhelmed.” What we need is a vision of the health service that the public needs and how we get there.


  • Competing interests: none declared

  • Provenance and peer review: commissioned, not peer reviewed


View Abstract