The UEC Crisis

Urgent and Emergency Care (UEC) is currently facing a crisis. While Wes Streeting recently re-committed Labour to the four-hour Accident & Emergency (A&E) target, this target has not been met nationally since July 2015 and in 2023/24 only 58% of patients were seen within four hours.¹ Meanwhile, the Royal College of Nursing declared UEC corridor care a “national emergency” in June 2024, with more than 1 in 3 nursing staff delivering care in inappropriate non-clinical spaces (such as corridors) during their last shift.²  

Rising UEC costs and ‘vicious cycles’ 

In addition to the unacceptable impact on patients access emergency care, this crisis has led to increasing UEC costs. For example, nationally, in-hospital UEC costs (as measured by National Cost Collection index for Emergency Care, Non-Elective Longstay and Non-Elective Shortstay) increased by 38% between 2018-19 and 2021-22, reaching > £29 bn of expenditure in 2021-22. These costs have continued to rise since. Indeed, UEC costs in some NHS Trusts have increased by 50% since 2018-19.  

However, increased spend on UEC is not leading to better patient outcomes or experiences. Rising costs are not only due to an increase in activity and rising inflation, but are also in part due to patients waiting for a bed to become available for admission. This is leading to ‘vicious cycles’ within UEC systems. As patients have longer waits in ED – often in corridors – their outcomes worsen and length of stay increases. This drives further bed blockage, leading to even longer waits and necessitating increased corridor care. Staff productivity is also impacted throughout the process, decreasing end to end productivity. Therefore, once long waits become the norm, there is no quick fix to break out of the cycles which end up only increasing wait times, impacting quality, safety and costs. 

‘Crowding out’ of other expenditure  

The scale of the UEC crisis – and the cost of addressing it - means that systems have had to allocate increasing funds to UEC at the expense of other areas of care. Indeed, the rate of growth in in-hospital UEC costs dwarfs the rate of growth of primary care costs, or social care costs, or other in-hospital costs. This rate of growth is driving local deficits, and is also crowding out other types of activity and expenditure, both in-hospital and out-of-hospital.  

The ‘crowding out’ of other expenditure greatly reduces financial allocative efficiency. This is because Non-Elective Long Stay is amongst the least attractive activities to perform in terms of health gain relative to cost. Therefore, identifying and addressing the root causes of UEC challenges can improve quality and safety, as well as wider financial performance.  

Identifying root causes of poor UEC performance and increased costs  

The PSC has been conducting ICS-level work across Trusts and Local Authority catchment areas to identify the drivers behind end-to-end UEC performance. This includes looking at population health, acuity and change in long term condition (LTC) prevalence, primary care metrics, in-hospital metrics, community services and intermediate care, and downstream at social care. 

While UEC systems are under pressure everywhere, The PSC’s work has found a surprising amount of variation in how performance problems manifest at different points of the end-to-end pathway in different localities. Likewise, the root causes of poor performance varied between localities. Elements such as high levels of acuity, high levels of staff turnover, staff shortages, challenges with social care and discharge, patient flow in hospitals and primary care capacity were some examples of interlinked causes across localities.  

This variation therefore makes understanding these drivers crucial – as any solution must be targeted at the right root causes. 

Implementing solutions to improve quality and safety, and reduce costs 

So what can be done? Due to the highly interdependent nature of the UEC system, de-escalation is essential to reverse the knock-on cycles, which affects quality, safety, and costs. This requires collaborative place-based working across key areas including acute activity avoidance, in hospital flow optimisation and supporting downstream flow and acute discharge.     

Specific interventions with a strong evidence base that can address some of the root causes include Same Day Emergency Care (SDEC) models of care and end-to-end end of life care that keeps patients in the home. Both interventions focus on deflection and admissions avoidance. Under the SDEC model patients presenting at ED with certain conditions can be assessed, diagnosed and treated without admittance. The PSC’s work supporting more than 20 provider and commissioner organisations across five Integrated Care Systems to translate national and regional SDEC policy priorities into practice demonstrates the success of these measures. Likewise, improved end-to-end end of life care can support patients to remain in their homes and proactive response and intervention can identify and support the top 20 care homes for ED attends in a certain locality.   

However, these solutions will only work if they are tailored to the local context and local UEC performance needs. Implementing solutions such as these will also take effort and time, and require the reallocation of funds away from emergency UEC spending once some UEC improvements begin to materialise.  

There is a real opportunity here for improvement, despite the current UEC challenges and local variation. There are known, well-evidenced initiatives to address some of these causes and turn the vicious cycles into virtuous ones. In addition, it is currently summer. Acuity and weekly deaths are currently at their annual seasonal minimum, making this the best time to make change in UEC. In addition, deaths and acuity are down this year relative to 2023 - again making this the time to make change. Now is the time for action, to begin to address some of these causes before the winter pressures set in.   

To find out more about how The PSC can help you identify and understand the root causes of UEC performance and how we can co-design tailored initiatives to address these, please reach out to Russell Cake (russell.cake@thepsc.co.uk).  

[1] https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/accident-emergency-waiting-times#:~:text=18%20December%202023-,A%26E%20performance%20continues%20to%20decline,were%20seen%20within%20four%20hours.

[2] https://www.rcn.org.uk/news-and-events/news/uk-corridor-care-rcn-declares-national-emergency-and-demands-political-action-030624