Reversing the urgent and emergency care spiral of decline

NHS urgent and emergency care is under intolerable strain. This strain is increasingly causing harm to patients.1 Timely and high quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints.23 While the covid-19 pandemic has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decades long and unless urgent action is taken, we may not yet have reached its nadir.

In January 2023, 42 725 patients waited more than 12 hours in England’s emergency departments for an inpatient bed. This compares to 16 558 in January 2022 and 2,847 in January 2020. This is further illustrated in the data from March 2023 with 39 700 patients waiting more than 12 hours in emergency departments compared to 22 500 and 1,184 in the same month of 2022 and 2020 respectively. The rate of this rise is gravely concerning with a current trajectory suggesting that winter 2023 will be worse than the dire experience of 2022. In 2022, 1.65 million people waited 12 or more hours in an emergency department.4 In February 2023, 125 505 patients (around 10% of attendances) waited more than 12 hours from the time of emergency department arrival.

Acute medical care is now routinely being delivered by teams in emergency departments rather than in optimal environments with older patients in particular bearing the brunt of this situation. This causes significant risk and increased mortality.5

Acute medicine is at the heart of finding opportunities to mitigate the current crisis and future innovative, adaptive, high quality and sustainable urgent and emergency care. The fundamental components of the specialty—well functioning, evidence driven acute medical units and ambulatory emergency care, recently rebranded in England as same day emergency care—alongside enhanced care areas and evolving acute medicine led hospital at home models are essential for urgent and emergency care and whole system recovery.678

The Society for Acute Medicine Benchmarking Audit (SAMBA) reiterates the picture of a rapid decline in clinical performance.9 Acute medical patients are not only enduring long waits in emergency departments; but also increased waits for key indicators of quality such as initial clinical review, time to consultant review and monitoring of their physiology.

Well resourced analysis and understanding of patient flow informing the delivery of local services is imperative. Inadequate or inappropriate use of direct acute medical unit admission or same day emergency care pathways contribute to long waits in emergency departments exacerbated by a lack of inpatient beds to facilitate flow from the acute medical unit alongside a mismatch between staffing levels and peaks of activity exacerbated by workforce shortages. The ideal acute medical unit needs sufficient capacity to process acute admissions and keep patients who do not require transfer to a specialty unit to stay for up to 72 hours, as this continuity reduces length of stay. Bypassing acute medical units to general medical or specialty beds can increase length of stay.

An increasing range of presentations no longer require patients to remain in hospital overnight and are managed through same day emergency care pathways. Acute medicine hospital at home models enable acute care traditionally delivered in hospital to be provided in the patient’s home. The design of these services includes senior clinician decision making, multi-disciplinary assessment and rehabilitation, physiological monitoring utilising digital technologies, delivery of intravenous treatments and escalation plans should there be a deterioration in the patient’s condition.10 These can be supported by diagnostic investigations at the bedside including point of care blood tests and point of care ultrasound.1112

However, for these and other novel services to be optimally utilised and embedded in clinical services, robust evidence is needed to understand how to select patients for each service and what the health economic, service benefit, and opportunity costs are for each model. Recent history has shown that assessment and care pathways that conceptionally appear sensible, but have limited or no evaluation before roll-out, can perform poorly when deployed in real-world healthcare settings. For example, selection tools for same day emergency care,13 the performance of covid virtual wards,14 and NHS England’s “Reasons to Reside” criteria,15 have all failed to meet expected performance levels when evaluated. Acute medicine offers significant opportunities for service innovation, but this must be as part of a learning health system,16 where services are evaluated and refined in accordance with evidence.

Alongside its core work, acute medicine can promote and deliver important public health messages.17 Delivering patient health education is often sacrificed in overburdened acute environments, with a lost opportunity to potentially mitigate future unscheduled admissions.

Acute medicine services, like all NHS and social care, are wilting and unable to meet demands. Patient complexity and expectation will continue to increase for the foreseeable future. While acute medicine must continue to evolve and adapt, it is imperative that the proven fundamentals are not overlooked in the likely futile search for the “magic bullet.” High quality research, consistent implementation, and rigorous evaluation of new initiatives to understand acute medicine flow and performance are mandatory.

NHS acute medical pressures are at unsustainable levels and current results are scant justice for the teams who continue to strive to deliver reasonable quality of care for their patients. Critics argue that senior doctors highlighting failings in the delivery of urgent and emergency care is not new; what should we expect in the winter with seasonal illnesses and an increasing population of older people? However, this notion must be dispelled. The decline has been sustained; it existed before covid-19 and has accelerated rapidly in its wake. While it is true that more people are accessing emergency care, this increase alone does not explain the disproportionate drop in performance. This situation must not become an unacceptable new normal or indeed continue the current spiral of decline. The principles of acute medicine are essential to achieve recovery of urgent and emergency care, and it must be resourced to deliver its potential.