Section 1: How are changes in emergency services part of the NHS “right drift”?

Since 2010, UEC services have progressively crowded out many other types of health and care service. Figure 1 illustrates this, and illustrates that the trend of crowding out pre-dates COVID, and then got worse during COVID.

Figure 1: How growth in UEC expenditure (orange line) has overtaken and out-stripped expenditure on social care and planned care: the NHS is increasingly becoming an “emergency care service”.

This isn’t just a financial problem and a right drift problem – it’s also a quality and safety problem within UEC services, as illustrated by the national growth in the number of 12-hour waiters in ED, and by ONS’s research about the potential mortality impact of those waits.

Unless this crowding out is addressed, it will be very difficult for the government to address planned care waiting times successfully, and very difficult for the government to gain the headroom to “shift from treatment to prevention”.

Section 2: What are the root causes of the right drift in NHS service?

As illustrated by the charts below, there are three key root causes of the financial growth in UEC services, and of the crowding out that UEC therefore causes:

1. UEC activity - in particular, emergency admissions - is growing faster than the population, and faster than the age-weighted population[1]
2. Reversal of the pre-COVID trends of year-on-year reductions in average patient length-of-stay in hospital
3. Real-terms increase in the cost per occupied bed day

[1] Age-weighted population takes account of the fact that the elderly need more healthcare per capita than younger populations, and takes account of the ageing of the population in the UK. As a result, age-weighted population in the UK has been growing faster than the total population.

Figure 2: Illustrating the long-term trend of emergency admissions growing faster than England's age-weighted population (typically an additional 1% of growth every year)

Figure 3: Illustrating the pre-COVID trend of year-on-year reductions in length of stay, followed by an increase in length of stay during and after COVID, which has yet to be recovered. The gap to the trend-line is now 19%

Figure 4: Illustrating the long-term trend for increased cost per non-elective bed day. Note that some of the COVID-related increases have recently been eliminated, with real-terms cost per bed day still 44% higher in 2022/23 than in 2011/12.

It should be noted that, while some of the higher cost per occupied bed day that occurred during COVID has been eliminated, it is unlikely to be possible to bring these costs back – in real terms – far below where they were in 2019/20. Some of the increase between 2011/12 and 2019/20 was associated with richer staffing at evenings, overnight and weekends, which would be hard to roll-back in a service that now operates much closer to a 7-day basis.

The recent productivity improvements that NHS England has noted are driven by the recent length of stay improvements shown in Figure 3, and the recent reductions in real-terms cost per occupied bed day shown in Figure 4. These are important and good improvements – but not yet happening nationally at the pace required to avoid crowding out.

Section 3: How are some NHS systems and Trusts reducing length of stay and emergency department waits?

Following a whole system improvement effort in Hull and the East Riding of Yorkshire, commissioned by the local authority and supported by the ICB, acute and community providers have successfully reduced overall length of stay - particularly length of stay for the longest-staying patients, as shown in Figure 5, below:

Figure 5: Illustration of success in reducing bed days for patients with 21+ day LOS, Hull & East Riding of Yorkshire

Maidstone and Tunbridge Wells is an example of a Trust that has been successful through focused efforts over 7+ years, as shown in Figure 6, below.

Figure 6: Illustration of MTW's long-term relative success in reducing its dependence on General & Acute beds. By summer 2024, it had opened a 19% gap relative to England as a whole

Maidstone and Tunbridge Wells combines this reduced dependence on General & Acute beds with good performance on a range of indicators. For instance it has a much lower-than-average ratio of 12-hour waits in ED relative to attendances and has a much better-than-average 4-hour wait performance too.

NHS England’s datasets also reveal other organisations that are succeeding. For instance, University Hospitals of Morecambe Bay, previously a struggling trust in System Oversight Framework Four (SOF4), has shown sustained 24% reduction in length of stay since Spring 2022, and a 6% reduction in dependence on General and Acute beds since the end of 2022.

Section 4: What ingredients make the difference for NHS Trusts and Systems seeking to improve UEC performance?

The saying goes that “culture eats strategy for breakfast”. The same appears true when it comes to delivering UEC service improvement. The PSC’s analysis shows that, more important than the choice of improvement initiative to implement, is paying attention to having the right environmental conditions for successful implementation of chosen initiatives. Organisations that successfully implement this change tend to have the following three environmental conditions in place:

1. Sufficient leadership and change management capacity to drive improvement, together with sufficient focus to address and overcome barriers as they inevitably arise.
2. “Healthy workforce”, where the dimensions of “healthy” include: a) sufficient levels of morale and psychological safety for front-line clinical staff to get involved with improvement, and hence for improvement to be locally and clinically-led; and b) vacancy rates below a threshold level, and use of agency staff below a threshold level
3. Use of data and evidence, combined with looking at value end-to-end along the UEC pathway, as opposed to managing cost in individual silos

Once these “right environmental conditions” are in place, we see a very wide range of initiatives that can and do work. These include:

• Technological improvements (leveraging both medical technologies and digital technologies, and noting that both the Hull example – OPTICA – and Maidstone & Tunbridge Wells example – Teletracking – had significant elements of this)
• Process and pathway improvements
• Changes to workforce roles and rotas to match changing patient needs, and the changing needs of new technologies and processes

Recommending improvement initiatives – even ones that have been successful elsewhere  – in the absence of the right environmental conditions has a poor track record.

Section 5: How can the NHS reverse the “right shift” both nationally and locally?

Benchmarking such as Model Hospital can show a performance gap between one system and another. However, where system recovery plans focus on understanding benchmark gaps, and potential initiatives (technology implementations, processes to improve etc.), without considering the environmental conditions for successful delivery, they are unlikely to succeed.

NHS England, its Regional Teams, and local systems, need to realistically appraise these environmental conditions – and how to move towards having the right conditions in place – as part of annual plans and recovery plans. Once those conditions are sufficiently in place, systems can then consider which initiatives have the best fit to local problems, as well as the best track record of return on investment and speed of payback.

We are hosting a roundtable on Tuesday 4th March 2025 16:30-18:00 to bring together health and care leaders from across the country to further explore transformation of UEC systems to reverse this "right shift". If you are interested in attending, please send an email to hello@thepsc.co.uk.

If you would like more information on these findings or to discuss how The PSC can support your organisation in tackling UEC challenges, please contact us at hello@thepsc.co.uk.