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‘The A&E Crisis Shows How the NHS Is Getting Worse and the Government Has No Real Plans to Fix It’

Politicians are refusing to take meaningful action to resolve the perma-crisis in our health service, writes NHS Doctor, David Oliver

Patients seen in a waiting room at a South London Hospital
Patients seen in a waiting room at a South London Hospital. Photo: Janine Wiedel Photolibrary / Alamy Stock Photo

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NHS Emergency (A&E) Departments are now in a year-round permacrisis which additional winter pressures and the annual surge of seasonal infections merely worsen. 

The dramatic and televisual nature of long waits, overcrowding, trolleys in corridors and cupboards, queuing ambulances and harrowing stories from patients, their families and A&E staff are an endlessly repeating staple of news reporting about the NHS.  

However, the root causes lie outside A&E itself in the wider health and social care system. They result from years of harmful policy decisions or complacent inaction over several parliaments.

What happens in A&E is a prominent shop window into the current state of our services, systems, operations and capacity. I see no credible new plans for action on those wider causes, despite Wes Streeting’s supportive soundbites. 


Worsening A&E Performance Since 2010

Analyses of national NHS performance data show us just how badly performance has declined over the past 15 years. 

In December 2024, 28.9% of patients in English A&E departments waited more than four hours to be admitted, transferred or discharged.

In that one month, 154,689 patients waited more than four hours in A&E for an inpatient bed after a decision to admit them and 54, 207 waited for 12 hours. Ten percent of all A&E patients in 2024 waited more than 12 hours in the department, whether being admitted or not.  

In the first quarter of 2014, less than 150 patients waited more than 12 hours for admission to a bed, compared to 150,000 in the first quarter of 2024.

Staff at a UK hospital Photo: Nick Moore/Alamy

This is unacceptable and dangerous, as shop-floor clinical staff and their associations have been saying loudly.

In 2010, after many years of operationally focused reduction in A&E wait times, the coalition Government, who had driven this change, relaxed the previous national standard that 98% of A&E patients should be admitted, transferred or discharged within four hours to 95%, but it was still being consistently hit that year. That standard has not been met since 2015 and performance has declined ever since.

That Government has challenged NHS trusts to hit 78% by March 2025 as some kind of “stretch target” shows how bad things have got.   

The dramatically worsening performance cannot be explained away just by rising demand. There were 21.6 million A&E attendances in 2011/12 versus 26.2 million in 2023/2024.

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Long waits and overcrowding have a knock-on impact on ambulance services which now consistently miss national time standards for handing patients over to A&E staff. This in turn means hard choices between caring for patients in the back of the parked ambulance or in spaces not equipped for patient care.

And it stops crews getting out on the road for their next job, even though ambulance response time targets are now also consistently missed. 

There are human tragedies behind the dry datasets.  


The Human Cost

Long A&E waits and overcrowding are linked to higher death rates. A report this month from the Office for National Statistics showed that patients who wait 12 hours or more in departments are over twice as likely to die in the following 30 days as those waiting two hours or less. 

A 2024 study from the Royal College of Emergency Medicine estimated an extra 300 deaths a week associated with waits of longer than 12 hours. 

Staying for hours in a noisy, chaotic and rammed department, never designed for ongoing inpatient care is bad news, especially for frailer, older, confused or disabled patients. They can be left disoriented, distressed and deconditioned, worsening their health and the worry for their loved ones. 

Working in such a fraught environment for months and years on end is also hugely pressurised for clinical staff, leading to burnout or the “moral distress” that results from not being able to deliver the safe, compassionate standard of care they want to. 

The recent Royal College of Nursing Report “On the frontline of the UK’s corridor care crisis” provided a disturbing account of those experiences for patients and nurses alike, with personal testimony from 5,408 nursing staff.

Junior doctors are seen at the picket line outside St Thomas’ Hospital as they begin 6 day strike in London in January 2024. Photo:Tayfun Salci/ZUMA Press/Alamy

There is little immediate prospect of building a way out of the crisis when this month has also seen the postponement and watering down of the last government’s 40 New Hospitals” programme – which was always smoke and mirrors overpromising, as I wrote in Byline Times in 2023.  

The National Audit Office also recently reported a backlog of at least £49 billion in repairing public buildings with the NHS estate a major part of that. Analyses by NHS Providers and the Financial Times have also shown that the NHS spends a far lower proportion of its budget on capital expenditure for buildings and equipment than systems in comparable nations.

Upgrading A&E departments or Acute Medical Units or the IT to support them costs. And capital budgets always risk being raided to prop up revenue. 

Hospital A&E departments are pressurised from both ends. They have little control over demand at their front door from ambulances, the number and type of cases arriving, the availability of beds on their hospital’s wards, over capacity in community health and social care services that might help people stay at home, or leave those wards more quickly, nor the overall number of hospital beds. 

We did not get into this emergency by accident though. It is the result of numerous policy failures over many years. Here are some:


A Major Loss of Hospital Bed Numbers

The UK (and England even more so) has very few hospital beds by international standards. At 2.2 beds per 1000 people, we are at the bottom of the OECD league table and around half the EU average. 

For a population of 57 million, we have only 100,000 General and Acute Beds, and those beds are now routinely running at around 95% midnight occupancy. This makes every day a struggle to find beds to admit patients or to find patients to discharge from them, even when their trip home remains at risk of going wrong or ending in re-admission. Rammed full beds leave very little headroom for any surge in demand. 

We have lost over half our hospital bed base over the past 30 years, even as the population has grown and aged and the volume and complexity of patients has risen

Yet In 2000, The NHS National Bed Inquiry warned of the risks of NHS hospitals running routinely at over 90% bed occupancy, proposed an increase in bed numbers and the need for greater capacity in community and primary care services. 

A 2014 joint analysis by the Nuffield Trust and Financial Times estimated that on the trajectory at that time, if admissions continued to rise, an ageing and growing population would need an additional 6.2 million overnight stays in hospital by 2022, or the equivalent of 22 new average-sized general hospitals, without a major expansion of capacity in alternative services outside hospital. 

The Royal College of Emergency Medicine has repeatedly warned of the risks of further bed closures and the need to increase capacity, most recently calling for an additional 10,900 beds to ease pressures and get bed occupancy down to 85% to create some headroom. 

And when brand new hospitals have been built in recent years, for instance in North Bristol, Liverpool and the West Midlands, they’ve always had fewer beds than the ones they replaced despite the warnings and obvious risks.

Overoptimistic consultancy assumptions about reduced demand have not helped the thinking. Nor has the Private Finance Initiative which drives bed reduction to help reduce costs and increase margins. 

NHS England’s promises in 2023 to increase bed numbers by an extra 5,000 as part of its promised “acute care recovery plan”  and provide the funding have amounted to very little.

Contrary to frequent popular narratives, the main reason for the long A&E waits is patients who are sick enough to need a bed with no beds available and not those with less serious issues who will attend and go home on the same day. So “flow” into and out of inpatient hospital beds is the key block. 


A Shortage of Community and Primary Health Services

Even within the beds, we do have, around 12% are currently occupied by patients who are medically fit to leave but cannot do so – largely due to delays in accessing step-down support when they’re discharged. This takes yet more available beds out of commission. 

This support can be in social care services either at home or in residential or nursing homes, or in needs and financial assessment processes needed to access them. It can also be in community NHS services, for instance in home-based community rehabilitation, palliative care, hospital at home, remote monitoring, community hospitals or in equipment and adaptations required to help support people outside hospital.

Yet, National Audit of Intermediate Care has estimated that we only have around half the places we need to help keep people out of avoidable hospital stays. 

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Crucially, a similar range of services can support people either to leave straight from the A&E department or to avoid attending it, if they are organised as a rapidly accessible alternative, 

Some of those stranded inpatients are there precisely because admission to a bed was the only available support available. Once they are inpatients, they risk further deterioration and harm from the hospital environment or pressure from families not to discharge them.  

There are also major gaps in district nursing and health visiting and we are well short of the capacity we need in those alternative community health services outside hospital.

With millions of older people relying on unpaid care from family members to support them at home, those same services can support the carers. Yet as the annual “State of Caring” survey makes clear — that support is sorely lacking.


No Social Care Policy Solutions

Free Adult Social Care is already heavily rationed and restricted to those with very high levels of need and low means. All others with needs face personal costs or are unable to access support.

Local authorities and their departments of adult social care face serious financial challenges. Around one in nine posts in social care remain unfilled. Care homes and care provision companies are struggling for viability. 

The Coalition Government initiated severe cuts to local government and hence social care budgets, which the sector has yet to recover from. Free Social Care support is already restricted to people with very high levels of need and with low means.

There are huge gaps in provision and around one in nine social care vacancies are unfilled — with immigration rules not helping. Care homes are struggling for viability and capacity and we have failed to invest sufficiently in age-friendly housing. 

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Around half of “delayed transfer” patients stuck in hospital are waiting for social care needs to be assessed or funded or home care to be sourced. Others find themselves admitted acutely to hospital because of housing problems or care needs or carer stress. 

The past 15 years have seen repeated false dawns, about-turns and broken promises in identifying solutions for social care funding, provision and access or workforce retention.  This included the 2011 Dilnot Commission, whose recommendations were ultimately sidelined, despite twice being legislated for. 

Labour ducked meaningful commitments on Social Care in its election manifesto. And apart from legislation for a fair pay agreement, they have made zero plans to improve local government funding.

Yes, they have announced yet another social care commission, to be chaired by Baroness Casey. It will not report till 2028 but social care is drowning right now, with no rescue in sight. 


The Crisis in Primary Care

Contrary to some popular narratives, poor access to GPs is not the major reason for long waits and overcrowding in A&E and accounts for a minority of attendances. However, there has been no increase in the number of qualified GPs since 2010, even as annual consultation numbers have increased to over 330 million a year, compared to only 26 million A&E attendances.. 

GP list sizes now average around 2,000 per doctor. Yet GP partnerships only receive around £150 per patient per annum for unlimited consultations. NHS GPs see far more patients daily than their counterparts in other high-income nations.

And despite increased recruitment to GP training posts, the number of doctors burning out, leaving or reducing hours has countered any gains. You cannot recruit your way out of a retention crisis.  Yet the current GP contract is also making it hard for partnerships to recruit additional qualified GPs who are struggling to find work. 


No Political Solutions on the Horizon

Labour’s 2024 Election Manifesto pledged precious little to urgent and emergency care. And since the election, despite the announcement in their first budget of a multi-year funding uplift for the NHS, they have pledged nothing of note since.

Look for concrete, costed commitments with clear targets and the focus has been on reducing waiting lists and waiting times for elective (planned) care, with urgent care an afterthought. 

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Ministers repeatedly mouth soundbites around the “3 big policy shifts” — moving services  “from hospital community”, “from analogue to digital” and “from sickness to prevention”, along with other rhetoric like “bringing back the family doctor”. But where are the logistics, the resources, the workforce,  the milestones?

Not only have they failed to grasp the seriousness of the current crisis in urgent and emergency care and failed to prioritise it. They have also given few meaningful plans to tackle the whole system issues that led to it.

On 23 January, the Health Service Journal reported a leaked “confidential working draft” of an NHS England plan for urgent care recovery. Despite being an arm’s length body, the reality is that NHS England is directed and constrained by the Government of the day.

If and when the plan is finalised, we can see how serious it is.


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