The global pandemic has brought with it enormous challenges on a scale never seen before in our lifetimes. Health services in England have radically altered in order to prepare for a rapid rise in Covid-19 cases, and the urgent and emergency care system has been put to the test.
A nationwide lockdown was brought into effect, which itself introduced new and unique challenges for the health service. But the virus has spread at varying speeds in different parts of the country.
So what effect has Covid-19 had on urgent and emergency care across different regions of England? It has been widely reported that A&E attendances have dropped significantly. But what’s happened to 111 call volumes? How have ambulance response times changed? And what about trolley waits in hospitals?
We follow the patient journey through urgent care services, from 111 calls, through to ambulance services and hospital admissions, drawing out the regional differences.
Has Covid-19 hit some regions of England harder than others?
Since the start of the outbreak, London has been the most affected region, with 24,993 cumulative lab-confirmed cases and 5,398 hospital deaths recorded by the end of April. This is not a surprise, with London being a hub of globalisation, international travel and commerce – probably enabling the virus to spread further prior to lockdown. Conversely, the South West has been the least affected region, with 6,462 cases and 988 hospital deaths as of 30 April.
How has the urgent and emergency care system coped in different regions of England?
The outbreak brought an influx of people requiring advice and support for coronavirus, and people were encouraged to phone NHS 111 in the first instance. On 26 February a new 111 online service launched to help with the surge in call volumes, with enquiries reaching record highs.
The percentage increase in 111 calls between March 2019 and March 2020 was highest in London (+48%) and lowest in the North East and Yorkshire (+29%). This follows the general pattern of London being the area most affected by Covid-19, with more people calling for advice about symptoms. However, the increase in 111 calls was not strongly correlated with the spread of coronavirus across the other regions.
In April, 111 call volumes fell back down across all regions (see chart below). The decline in the South East is notable, with the number of 111 calls dropping to below 180,000 – the lowest it has been since September 2016.
Ambulance response times
The change in ambulance response times paints an even starker picture of the impact of Covid-19.
For Category 2 (emergency) calls, between March 2019 and March 2020 the mean response time increased by 43 minutes in London, but decreased by 1 minute 50 seconds in the South West. For Category 1 (life-threatening) calls, the response time increased the most in London, to 9 minutes 52 seconds – well above the target response time of 7 minutes.
Ambulance trusts are supposed to respond to Category 2 calls within 18 minutes, but in March 2020 the average wait in London exceeded 1 hour (see chart below), and 10% of calls took longer than 2 hours 20 minutes. It is unclear whether this occurred because of the additional time needed to disinfect ambulances, staff sickness due to Covid-19, or simply an increase in 999 calls. Neighbouring ambulance trusts stepped in to help, with some firefighters driving ambulances. This may have contributed to the enormous improvement in response times seen in London in April.
In fact, there were improvements across all regions: in the North East and Yorkshire, Midlands, East of England, South East and South West, ambulances responded the fastest ever since the current targets were introduced. This corresponds to a drop in the number of incidents responded to and the number of calls that were made, but may also reflect a decrease in road traffic and other urgent incidents because of the lockdown.
In April, A&E attendances dropped to their lowest levels since records began in 2010. The reasons for this are likely to include the campaigns encouraging people to phone 111 as a first point of call to avoid the health system becoming overwhelmed, the reluctance of people to attend hospital for fear of contracting Covid-19, and the introduction of the lockdown that told people to “stay at home”.
Regionally, between April 2019 and April 2020 the largest percentage reduction in major A&E department attendances occurred in London (-52%) and the lowest reduction occurred in the North West (-45%). The regional variation here is minimal, which indicates that the fall in attendances is less related to the spread of Covid-19 and more to changes in the public’s behaviour as a result of lockdown. These changes may have had some positive effects (such as fewer accidents occurring outside the home) as well as negative effects (patients staying at home that should be seeking help).
Despite A&E attendances plummeting, the target for people to be admitted, transferred or discharged within four hours was still not met. In March 2020, performance was worse in all regions compared to March 2019. And in April 2020, although an improvement was seen in all regions, performance in London was only 1 percentage point better than in April 2019.
‘Trolley waits’ are the time patients wait between a decision to admit them and them arriving on a ward. Waits of over four hours increased slightly in London (+4%) and the North East and Yorkshire (+8%) between March 2019 and March 2020, but decreased in all other regions. By April, trolley waits had dropped substantially in all regions, which may indicate that hospitals were managing the flow of patients better than usual. This also goes hand-in-hand with the decrease in A&E attendances, the rescheduling of elective care procedures and operations, and the measures taken to increase hospital capacity.
Between April 2019 and April 2020, the largest decrease in trolley waits (of -90%) occurred in the South West, the area least affected by the virus, while the smallest decrease (of -43%) occurred in London. Even with the halving of A&E attendances, over 5,000 patients in London waited longer than four hours for a hospital bed, and 232 patients waited for over 12 hours.
How will different regions of England cope in the coming months?
At the time of writing, London remains the region with the largest number of Covid-19 cases and deaths, while the South West has been least affected. At the peak of the outbreak, there appears to have been a larger increase in 111 calls and ambulance response times, and a smaller decrease in trolley waits in London compared to other regions. The drop in A&E attendances occurred almost unilaterally across all regions – more related to the nationwide lockdown than to the outbreak itself.
As the lockdown is gradually lifted, there are important things to take away from these findings. The sharing of resources across the country (such as the London Ambulance Service being supported by neighbouring crews and vehicles) has proved to be a success. In advance of health care activity increasing again and a possible second wave of infections, this idea could be extended to minimise some areas being more affected than others. An example would be managing waiting lists for treatment and diagnostics across areas and between different health providers.
A&E attendances dropped to record low levels in April, and keeping demand close to current levels may be necessary for urgent care in coming months. Separating infected and non-infected patients will be paramount, which will have major implications for clinical models and the flow of patients through hospitals. ‘Covid-free’ hospitals or floors, adjusting to a lower bed occupancy rate, and centralising specialist intensive care services for Covid care may help to reduce the burden in some areas.
Ultimately, widescale changes in infection prevention, staffing capacity, building facilities and patient management will be needed. Learning as much as we can about how different areas and services dealt with the first wave of infection will be crucial if the health service is to cope.
Morris J (2020) What has been the impact of Covid-19 on urgent and emergency care across England? A Q&A. Nuffield Trust comment