Postcode lottery in urgent and emergency NHS care highlighted by PAC report

25 October 2023

Wide regional variations in ambulance response times with not enough done to tackle delayed hospital discharges
Uncosted long-term NHS workforce plan could lead to unsustainable financial pressures

How quickly an ambulance will arrive depends too much on where a patient lives. In a report published today, the Public Accounts Committee (PAC) warns of wide regional variations in the quality of patients’ access to urgent and emergency care. The report further warns that not enough is being done to tackle delayed discharges, with beds unable to be released for new patients.

The PAC’s report finds that ambulance services covering large rural areas, for example services in the South-West and East of England, were particularly challenged and disproportionately affected by problems stemming from the flow of patients elsewhere in the system. Average ambulance response times for the most serious incidents varied from 6m51s (London) to 10m20s (South-West) in 2021-22. Average 999 call response times ranged from 5.4s (West Midlands) to 67.4s (South-West).

The PAC’s inquiry explored why delayed hospital discharges had increased. The number of patients staying in hospital despite no longer needing to be there averaged 13,623 across Q4 of 2022-23, up from 12,118 during the same period in 2021-22. The report highlights a number of reasons for this: problems discharging older patients from hospital into adult social care, and delays in hospitals’ own processes, transfers to NHS community settings, or with the provision of short-term care packages, or nursing or residential care. This last group can wait sometimes up to five weeks from when they are ready to leave hospital.

The NHS has not met targets for ambulance handovers since November 2017, and for A&E waits since July 2015. Given long-standing declines in performance, the PAC is not convinced NHS England (NHSE) has been sufficiently held to account for meeting targets and improving urgent and emergency care, an area in which the Government must improve.

There is a risk that future unsustainable financial pressures are built into the unfunded and uncosted NHS Long Term Workforce Plan, which only includes a commitment of an additional £2.4bn to cover training costs for the first five years of the 15-year plan. The report also highlights very high levels of staff ill health and turnover rates, with the PAC left unconvinced by NHSE’s approach to address workforce shortfalls. NHSE hopes to retain 130,000 staff who would otherwise leave over the next 15 years, an aspiration which seems highly doubtful given multiple dependencies on other factors and unknowns.

Chair's comment

Dame Meg Hillier MP, Chair of the Committee, said: “Anyone who has had recent contact with the NHS knows it is in crisis. Patients suffering long waits and hard-pressed staff working in a system which is not delivering deserve better. The PAC’s role is to analyse the underlying numbers, and attempt to provide a Get Well Soon plan for the NHS.

“Excluding demand-led spending such as welfare payments, health takes up approximately 40 per cent of day-to-day budgeted spending by Whitehall departments. It is vital this is delivering benefits for patients. The Government and health system need to be alert to the serious doubts our report lays out around the workforce crisis, both the approach to tackling it now and the additional costs funding it in the future.”

PAC report conclusions and recommendations

The NHS has more money and staff than ever before but has made poor use of it to improve access for patients when they are in urgent need. The NHS is spending more money year-on-year in real terms, with its £152 billion budget in 2022-23 being £28 billion more than its budget in 2016-17. It also currently has record numbers of staff, including double the number of doctors in emergency departments compared with 2009. Despite this, the performance of urgent and emergency care services has been deteriorating for many years and while NHS productivity had been improving before the COVID-19 pandemic, it subsequently fell 23% over the two years 2019-20 and 2020-21. NHS England’s projection of future staff requirements in its workforce plan assumes staff productivity will increase by 1.5% to 2% annually but lacks meaningful detail on how this will be achieved. The NHS currently does not have effective metrics to manage patient flows between different parts of the system, and investment in technology and infrastructure improvements will be critical to improving productivity. However, the Department does not appear to have budgeted for any such investment and NHS England’s existing plans lack ambition given the scale of the issue at hand.

Recommendation 1: a)NHS England should write to the Committee within six months to set out its understanding of the causes for the fall in NHS productivity after COVID-19 and how it will address them, including how it intends to reduce staff absences.

b) The letter should also set out how it plans to better capture and manage patient flows across the whole system and, confirmation of what, if any, costed and budgeted plans it has for investment in technology and infrastructure improvements in this area.

NHS England’s improvement plans rely on better staff recruitment and retention to address significant shortfalls in the NHS workforce, but we are not convinced that NHS England’s current approach will achieve its very optimistic assumptions. NHS England has identified a potential shortfall of 260,000 to 360,000 staff by 2036-37, compared with a current shortfall of approximately 150,000 full-time equivalents. It intends to address this through ramping up recruitment, improving retention, and reforming work and training practices. NHS staff are currently experiencing very high levels of physical and mental ill health, particularly in the wake of the COVID-19 pandemic, with the most recent 5% sickness absence rate reported for 2022-23 above the long-term average of 4.2%. NHS England estimates that the rate of staff turnover in the health service was 9% in 2022-23. NHS England hopes to retain 130,000 staff who would otherwise leave the NHS over the next 15 years and stated this will be cost neutral. However, the realism of the assumptions underpinning this aspiration seems highly doubtful, given NHS England has identified multiple dependencies on other factors and unknowns.

Recommendation 2: NHS England should write to the Committee within six months to provide an update on progress with reducing staff shortfalls and improving retention rates. This update should include details of action it has taken and an assessment of whether its original assumptions have proved accurate.

The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. For example, in 2021-22, average ambulance response times for the most serious incidents varied from six minutes 51 seconds for the London ambulance service to ten minutes 20 seconds for the South-West ambulance service, and average 999 call response times ranged from 5.4 seconds for the West Midlands ambulance service to 67.4 seconds for the South-West ambulance service. The length of stay in the worst performing areas for discharging patients when they are medically fit is over double that of the best performing areas. Local management of systems and digitisation are likely to play a critical part in patients’ access to services, but one in ten trusts still lacks an electronic patient record and only four trusts have an electronic bed management system that could be described as first class. NHS England only has plans to upgrade 16 further systems, but it is working with the Department on a business case to expand this capability. NHS England has identified where there is good practice and poor performance but is weak at implementing and rolling out best practice more widely.

Recommendation 3: As part of its Treasury Minute response, NHS England should clearly set out the causes of variation in performance, and the specific initiatives it takes responsibility for to bring the worst-performing organisations closer to the standards being achieved by the best.

Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn slows admissions from A&E departments, which in turn slows the rate at which ambulances can hand over new patients, which then reduces ambulance capacity and therefore the timeliness of ambulance responses. More patients are remaining in hospital when they no longer need to do so. In Q4 of 2022-23, there was an increase of 12% in patients remaining in hospital despite no longer needing to, compared with the same period in 2021-22. Each unnecessary delay is a bed that cannot be released for a new patient. While a proportion of delayed discharges can be attributed to problems discharging older patients from hospital into adult social care, NHS England acknowledges that the challenge does not lie entirely in social care and more work was needed in the hospital sector.

Recommendation 4: As part of its Treasury Minute response, the Department should set out what it is doing to address delayed discharges caused by constraints within hospitals, problems in NHS community services, and shortfalls in social care.

Given long-standing declines in performance, we are not convinced the Department has sufficiently held NHS England to account for meeting targets and improving urgent and emergency care. The Department holds the NHS to account for performance in urgent and emergency care. It told us it works closely with NHS England and that, together, they hold a shared analysis of the key issues in urgent and emergency care and an agreed view on the solutions that are needed. However, the NHS has not met targets for ambulance handovers since November 2017 and for A&E waits since July 2015, with wider declines in performance across the board. Against this background, we asked how effective the Department has been in holding NHS England to account for the declining performance. While the Department was at pains to say how closely it worked with NHS England and had a shared analysis, it did not articulate how it was adding any value in holding NHS England to account for making meaningful improvements to services for patients.

Recommendation 5: The Department must improve how effectively it holds NHS England to account for performance against targets for access to urgent and emergency care. It should clearly articulate the respective roles of the Department and NHS England and set out the key steps the Department takes when its monitoring highlights underperformance.

The unfunded and uncosted NHS Long Term Workforce Plan risks building in unsustainable financial pressures. The NHS Long Term Workforce Plan drawn up by NHS England only includes a commitment of an additional £2.4 billion to cover training costs for the first five years of the 15-year plan. The plan does not include any estimate of total additional running costs for the significant increase in workers it has identified, such as salaries for an extra 260,000 to 360,000 staff. There is no information available on either the scale or source of how staff costs in future years will be met. Neither is there any cost or funding information on the other enablers without which the plan will fail for patients, such as expenditure on other salaries, estates, technology, and infrastructure. The true cost to the taxpayer of the plan will certainly be far higher than the amounts shared so far, but the Department would not commit to providing us or the NHS with longer-term certainty.

Recommendation 6: As part of its Treasury Minute response, NHS England should provide an update to the Committee on the full cost of implementing its workforce plan over the next 15 years, including ongoing staff costs, training and recruitment costs, and the costs and underlying assumptions of necessary wider enablers such as technology and innovation, social care, and infrastructure.

Further information

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