Intended for healthcare professionals


Unprecedented? The NHS crisis in emergency care was entirely predictable

BMJ 2023; 380 doi: (Published 09 January 2023) Cite this as: BMJ 2023;380:p46
  1. Adrian Boyle, president
  1. Royal College of Emergency Medicine

The problems in emergency care are fixable, but it requires political will and investment, writes Adrian Boyle

The past decade has seen progressively more severe winter crises in the NHS. This winter has reached an even more desperate low. Looking at any performance measure—ambulance handover delays, waits in emergency departments, or calls to primary care, 999, and NHS 111—shows a clear picture of a system under immense stress. Behind these numbers is a lot of avoidable human suffering. Heartbreaking stories have been shared in recent weeks of poor care in corridors, overfull wards, and staff run ragged.

A fifth wave of covid-19, an unexpectedly early and nasty group A streptococcus outbreak, and a return to a usual flu season did not help, but the fundamental problem was a lack of capacity in terms of both workforce and beds. The UK has among the fewest hospital beds per head of any Organisation for Economic Co-operation and Development nation,1 and we entered December with the highest ever recorded levels of hospital occupancy.2 Furthermore, failure to reform the interface between acute hospitals and social care has resulted in around 10% of beds being used for patients stuck waiting for social care before they can be discharged.3

Meanwhile, the Office for National Statistics continued to report naggingly high excess mortality over 2022.4 While the causes are incompletely understood and certain to be multifactorial, it is plausible that long delays for ambulances and delayed or diluted care in emergency departments contributed. Previous scientific studies and analyses have confirmed an association between long emergency department stays and 30 day mortality.5 It was disappointing that some commentators went into data denial mode, rather than accepting that this is a crisis that demands urgent action.6

Causes and solutions

There is, however, surprising consensus about the causes of the crisis, with widespread acknowledgment that investing in social care is the quickest and most cost effective intervention to ease pressure on hospitals. This narrative has changed over the past 10 years, with much less focus on low acuity patients as a source of demand and a recognition that the problem is mostly confined to patients waiting on trolleys who need to be admitted to hospital. Despite consensus about the causes, there is much less agreement on how this can be fixed.

Many of the solutions being proposed are still based on recycled ideas taken from demand management. These interventions often lack evaluations or evidence to support them. Take, for example, public health campaigns advising people only to call ambulances and go to emergency departments when they think they have a life threatening condition. Most of my patients certainly try very hard not to come to emergency departments, but are frequently funnelled there because of the scarcity of alternative ways to access care. Any intervention like this should be routinely evaluated—knowing an idea doesn’t work is useful, and good evidence is the best possible aid to implementation. A collection of royal colleges and the Society of Acute Medicine published a useful position statement about how to improve pathways, which centred on three themes: improved communication between clinicians, logistics, and continuity of care.7

The media narrative has presented the crisis this winter as unprecedented, which is not entirely accurate. Last winter, the Royal College of Emergency Medicine called for urgent action to prevent these kinds of delays to patient care and pressures on staff happening again. During the summer, NHS England published perfectly sensible plans to improve capacity and resilience in urgent and emergency care, including by increasing the number of beds in England by 7000.8 Progress against this goal, has, however, been limited; estimates vary but there may have been no more than an extra 1500 general and acute extra beds this winter. Recruiting the workforce to look after these extra beds is difficult, but necessary.

Evaluating the success of the plans we made for emergency care is a depressing but necessary exercise in organisational self-reflection if we are to have any chance of avoiding similar problems next year. The recent turmoil in emergency care has led to calls for the entire model of the NHS to be changed, so that it is similar to European social insurance models, and comments that more money does not lead to improved care. Yet these responses miss the key point: this problem is fixable and has been fixed before in the UK. What we need is the political will and investment to make this happen.


  • Competing interests: none declared.

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