As with all parts of the health system, urgent and emergency care has been considerably impacted by the coronavirus (Covid-19) pandemic. Attendances at emergency departments fell to record lows at the start of the pandemic, while calls to NHS 111 surged. The number of people attending A&E has since increased, with reports that attendances are now reaching record highs, placing further pressure on a system which was already under considerable strain.
The urgent and emergency care system includes emergency departments but also other services such as NHS 111, ambulance services, and urgent GP appointments. NHS 111 has been piloted as a ‘front door’ to urgent care, with patients encouraged to call if they have an urgent medical need to be directed to the most appropriate service. This includes providing a booked time slot to attend an emergency department, with recent guidance setting a target that at least 70% of patients referred to an emergency department by NHS 111 should receive a booked appointment.
NHS England has recently consulted on proposed new access standards for urgent and emergency care. The headline four-hour A&E target is set to be replaced by a new bundle of measures, including the average time spent in an emergency department and the time to initial assessment. Data is not currently published for some of the new measures, and thresholds for performance have not yet been set.
In this indicator update, we look at trends in the quality of urgent and emergency care both before and during the pandemic. We also look at measures of other parts of the health system which affect urgent care services. Timely and effective community care can minimise potentially preventable emergency admissions, reducing pressure on urgent care services, and higher hospital bed occupancy is associated with delays in emergency departments. A summary of our indicators is shown below. Click on the links for more detailed content and analysis. For regular analysis of the latest urgent and emergency care data, see our NHS Performance Summary reports.
- Between April 2014 and March 2021, the percentage of NHS 111 calls answered within 60 seconds fell from 93% to 78%. Provisional data for May 2021 shows that 65% of calls were answered in 60 seconds (data not comparable to previous months).
- The percentage of NHS 111 calls which receive input from a clinician increased from 27% in November 2016 to 53% in July 2018, where it has since remained roughly constant. Between April and May, the percentage of calls with input from a clinician fell from 46% to 42% (data not comparable to previous months).
Ambulance response times
- The target that all ambulance trusts must respond to Category 1 (life-threatening) calls in 7 minutes on average was first met in March 2019. Since then, response times have fluctuated and in May 2021 the average response time was 7 minutes 25 seconds. The 90th centile target for Category 1 calls, set at 15 minutes, is consistently being met.
- The average response time standard for Category 2 (emergency) calls, set at 18 minutes, has only been met three times since its introduction in 2018 – in May, June and July 2020.
Ambulance handover delays
- Between the winters of 2010/11 and 2019/20, there was an upward trend in the number of ambulance handovers delayed by over 30 minutes.
- In 2020/21, the number of delayed ambulance handovers fell. Between Week 49 (w/c 30 Nov 2020) and Week 9 (w/c 1 March 2021) of 2020/21, there were 117,385 ambulance handover delays of over 30 minutes, compared to 164,275 in 2019/20. This corresponds to a fall in the number of patients arriving by ambulance at emergency departments in winter 2020/21.
A&E waiting times
- The total number of A&E attendances has been increasing over time, reaching over 6.5 million attendances in Q2 2019/20. In Q1 2020/21, the total number of attendances fell dramatically to 3.6 million during the Covid-19 outbreak, increasing to almost 4.3 million in Q4 2020/21 – 24% lower than in Q4 2019/20.
- The percentage of patients attending A&E that were admitted, transferred or discharged within four hours fell substantially between 2010 and 2019, dropping to an all-time low of 69% in December 2019. In June 2020, performance increased to 90% alongside the substantial fall in A&E attendances, but has since worsened to 76% in May 2021.
- The median A&E waiting time increased from 129 minutes in May 2011 to 174 minutes in December 2019, before falling to 165 minutes in April 2021.
- Trolley waits – the time patients wait between a decision to admit and the patient arriving on a ward – have increased considerably since 2010. Trolley waits peaked in January 2021, when 95,695 patients waited over four hours between the decision to admit and admission, and 3,825 patients waited over 12 hours, the highest number since records began.
Potentially preventable emergency admissions
- Between 2008/09 and 2019/20, the rate of emergency admissions per 1,000 population for ambulatory care sensitive (ACS) and urgent care sensitive conditions remained relatively constant. In 2020/21, rates of emergency admissions for these conditions fell, alongside a fall in total emergency admissions during the Covid-19 pandemic.
- Rates of emergency admissions for ACS and urgent care sensitive conditions improved for people aged 0 to 15 and 64 to 74 but worsened for all other age groups between 2008/09 and 2019/20. In 2020/21, rates fell for all age groups.
- Between 2019/20 and 2020/21, the emergency admission rate fell for all urgent care sensitive conditions except deep vein thrombosis and angina, where rates remained constant.
Hospital bed occupancy
- Between Q1 2010/11 and Q4 2019/20, the total number of NHS hospital beds (general & acute, learning disabilities, maternity, and mental illness) decreased by 11% from 144,455 to 128,943. In Q1 2020/21, following the onset of the Covid-19 pandemic, the total number of available beds fell to 118,510. In Q4 2020/21, the total number of beds increased to 122,312 (5% lower than in Q4 2019/20).
- The number of available general and acute hospital beds fell from 110,568 in Q1 2010/11 to 102,194 in Q4 2019/20. In Q1 2020/21, the number of available beds fell to 92,559, increasing to 96,313 in Q4 2020/21 (6% lower than in Q4 2019/20).
- In Q1 2020/21, the number of occupied general and acute beds decreased sharply to 58,420. The number of occupied beds increased to 79,898 in Q4 2020/21 (12% lower than in Q4 2019/20).
Violence in A&E
- Between 2016 and 2018, the percentage of Urgent and Emergency Care Survey respondents who ‘definitely’ or ‘to some extent’ felt threatened by other patients or visitors while in A&E remained constant at 8%.
Patients’ overall experience of NHS and social care services
- In 2018, 28% of Urgent and Emergency Care Survey respondents who had attended type 1 A&E departments rated their overall experience as 10 (very good) and 1.5% rated their experience as 0 (very poor).
Mental health crisis care
- In 2020, 72% of Community Mental Health Survey respondents said they knew who to contact out of hours within the NHS if they had a crisis.*
- Of those who knew who to contact out of hours and had tried in the previous 12 months, in 2020 over half (52%) of respondents said that they ‘definitely’ got the help they needed when they tried to make contact. 17% of respondents did not get the help they needed and 2% were not able to make contact.*
* Results are not comparable to previous years.
For more information and analysis on urgent and emergency care, see these Nuffield Trust blogs: