Intended for healthcare professionals


Workforce: the persistent victim of the covid-19 pandemic

BMJ 2022; 378 doi: (Published 11 July 2022) Cite this as: BMJ 2022;378:o1702
  1. Adrian Boyle, consultant in emergency medicine, president elect12
  1. 1Cambridge University Hospitals NHS Trust
  2. 2Royal College of Emergency Medicine

In the past week, 11 000 people were admitted to hospitals in England with covid and the picture in the devolved nations is likely to be similar. High rates of hospital admissions, even if the patients aren’t very unwell, are disruptive for the running of hospitals. Most in the UK continue to use open bays, and this makes wards inefficient and vulnerable to outbreaks. The UK has fewer hospital beds than almost any other European comparator and we can ill afford any loss of hospital capacity. While covid has undoubtedly worsened performance, crowding in emergency departments was a problem before the pandemic. Hospitals are now full, and our “inadvertent natural experiment” has shown that occupancy rates over 92% are invariably associated with full emergency departments and delayed ambulance handovers.

The recent increase in covid rates across the UK has been mirrored by staff sickness. Staff with patient facing roles are hit harder by an increase in community prevalence; they are more likely to become infected and are unable to work even if they are not feeling unwell. Isolation rules have become confusing and complex. All around the country, staff WhatsApp groups have been fizzing with distress flares as staff members test positive and childcare arrangements collapse at short notice.

There are frantic attempts to shore up battered and fragile rotas and rota coordinators are scratching their heads. Meanwhile there has been a steady increase in the number of staff off work with long covid. While many have been flexible and accommodating to try to maintain their services, there is increasing burnout and uncertainty as to when all this will end. Furthermore, burnout can translate into “burn away.” Many are reducing hours or taking early retirement. Complex and confusing pensions rules are a disincentive for senior doctors to take on extra work. Staff remaining in work suffer “left behind syndrome,” where pressure to do more with less is even greater.

Predictably this seemingly never ending cycle of overwork and stress is leading to poor morale. Amanda Pritchard, chief executive of NHS England, recently acknowledged the situation in urgent and emergency care, but there has otherwise been little public recognition of how difficult working in acute care is at the moment.

There needs to be an acknowledgment that the system is broken. No one is confident that a seriously ill or injured patient could call an ambulance, be attended to promptly, arrive at hospital, and be diagnosed, treated, and admitted to an appropriate bed within six hours.

Though individual politicians are aware of crowding in emergency departments and delayed ambulance handovers, there is little visible action from government, and events of the past week will make any significant action even less likely for now.

While the public may grow weary of hearing about pressures in emergency care, 2015 was the first time that elective surgery had to be cancelled because of hospital capacity pressures. In 2015, 12 hour stays in the emergency department were almost unheard of—now they are almost routine for admitted patients. I’ve heard that a quarter of emergency medicine clinical directors reported patients staying over 48 hours in May and we grimly joke that 24 Hours in A&E is not a documentary, it’s now a way of life. The patients most affected by this are those needing admission, increasing length of stay is associated with increased mortality.

Current waiting time performance on emergency department 12 hour length of stays is recorded and reported, but not published. The number of patients staying more than 12 hours is much greater than the published metric would suggest. Trustworthy data and information are an important first step in fixing the problem. Recycling previous winter plans, such as NHS England’s 2021-22 10 point plan for urgent and emergency care is doomed to failure. It makes no sense to repeat a plan that previously failed on all its points.

The workforce needs to feel valued and supported—which may sound trite, but simple things such as a locker, access to hot food, and a clean staff room are not routine.

Attempts to solve this problem need to be focused on the patients who need hospital admission and making sure the pathway is as efficient as possible. Capacity within acute hospitals needs urgently to be expanded to accommodate the predictable number of admissions and, in part, this means fixing the troublesome interface between acute hospitals and social care.


  • Competing interests: AB has received grants from the Health Foundation and Small Business Research Initiative to investigate emergency department crowding. AB consults to ElectronRx.

  • Provenance and peer review: commissioned, not peer reviewed.