Return to crowded A&Es and long ambulance delays will put patients at risk, warn experts

Hospital emergency departments are facing a return to dangerous overcrowding within weeks, with queues of ambulances waiting hours to hand over patients, accident and emergency doctors have warned.

A “system failure” of the wider NHS system to support patients means more people are being forced to turn to A&E, said Dr Adrian Boyle, vice-president of the Royal College of Emergency Medicine.

The number of patients turning up at hospital has already risen dramatically since January, when NHS trusts were in the grip of a second major surge and images emerged of ambulances being stuck for hours outside A&Es and 999 patients waiting hours for a response.

The Royal College of Emergency Medicine has told The Independent that as the country emerges from lockdown and patients return to hospitals with other health concerns, time is running out to fix underlying problems, meaning patient safety will be put at risk.

A&E consultant Dr Boyle warned: “The idea that we go back to normal is simply unconscionable. It’s actually worse than before in terms of what this will mean for crowding.”

He said hospitals had been forced to cut the numbers of beds because of the risk of spreading the virus on wards, but this meant fewer available for A&E patients to be admitted to.

Dr Boyle added: “We were in a terrible state pre-pandemic, the winter before the pandemic was the worst on record since we started collecting four-hour target performance. We are worried as lockdown eases we’re going to see an increase in demand, and still a fairly constrained and inflexible bed base.”

Images witnessed across England during the winter wave of ambulances queuing outside hospitals, having returned from collecting patients, will likely soon return, he warned.

“Prior to the pandemic it was seen as acceptable to put people alongside each other in corridors in emergency departments and that hid it from the ambulance service. What we saw in January, those distressing images of ambulances outside hospitals, reflected that people are anxious about not giving people infectious diseases when they’re in emergency departments so the crowding issue has partially moved outside into the ambulances. This is going to be more visible than it was before.”

NHS England has recorded a surge in A&E demand in recent months, with 1.3 million A&E attendances in February, a daily increase of 8 per cent compared to January. There were 422,000 A&E patients admitted to wards in February, up 5 per cent a day on levels a month earlier.

An analysis of data reported to the RCEM from 50 NHS trusts across the UK has found similar rising trends in recent weeks. It has also recorded more than 66,000 patients waiting over 12 hours for a bed at those 50 sites since the start of October.

In January, hospitals across England declared major incidents as ambulances were forced to queue outside A&Es for hours. In London and across the West Midlands the problem was so bad that patients dialling 999 were, in some instances, forced to wait seven hours or more for an ambulance response.

Dr Boyle warned overcrowding in A&Es was linked to increased risk of death for some patients, adding: “Crowding will make bad doctors out of good doctors. It impairs the level of care pretty much anywhere at any step of the process.

“It’s a basic function of an emergency department to be able to offload patients from ambulances. If an ambulance can’t offload, the person in an ambulance is not getting appropriate timely care because of the limits to how much you can do in the back of an ambulance.

“You’ve also got the fact that you’re taking an ambulance off the road, so you’re going to increase the times that serious cases get responded to, so there’s a second victim from that.

“In the era of Covid, the idea of also being stuck in a small metal box with a person coughing, for three or four hours, as a paramedic means you’ve been exposed to an enormous viral load of Covid.”

He said many NHS hospitals were treating far more patients than they were designed for, and most units did not have the physical capacity to cope with the numbers they were seeing before coronavirus. Now with the need to keep people socially distanced the problems are even worse.

The RCEM is calling on hospitals and NHS leaders to provide patients with more support to avoid them going to A&E as a default option.

Dr Boyle said: “Most people don’t want to go to A&E unless they absolutely have to. Frequently they’re there because they tried all the other alternatives, and the system has failed them.

“We talk about the emergency department as being the system failure service.”

The RCEM estimates the NHS is short of around 10,000 inpatient beds, which he said was equivalent to one or two wards in each hospital. Dr Boyle said the infection prevention measures to guard against Covid could have added another 2,000 beds to that figure.

He said: “I’m really worried about next winter if we don’t start doing something different in terms of the way we manage flow in our hospitals. We have a problem in this country that NHS hospitals find it very difficult to discharge people into social care. This in turn means that at any one time somewhere between 10 and 15 per cent of beds in acute hospitals are being used by people who do not need to be there.

“We have this summer to get our departments and our systems into shape so that we don’t end up with the awful pictures that we saw before. It wasn’t OK beforehand, and there seems to be a normalising of what is abnormal; it can’t be normal for ambulances to wait outside departments for ages and ages.”

NHS England said there were 1.97 million attendances in February 2020 compared to 1.27 million in February 2021.

It said there had been a 35 per cent fall in the number of ambulances waiting over 30 minutes from the end of December to February.

The NHS is investing £450 million to improve the handover of patients and streamlining of patients through A&E departments.

An NHS England spokesperson said: “While the pandemic inevitably had an impact on NHS capacity, including in A&Es, the NHS has redesigned critical care services, while also providing more convenient, Covid-secure ways to access care, including through NHS 111 First.

“The NHS has invested £450m in upgrading A&Es helping to improve ambulance handovers and we have significantly increased bed capacity so the public have been able to continue to come forward and get the care they need quickly.”