Improving urgent and emergency care services in England is a significant challenge as NHS England grapples with increasing demand and record hospital bed occupancy rates, according to a new National Audit Office report.

The report, Access to unplanned or urgent care, provides Parliament with a factual overview of NHS services available when people need rapid access to urgent, emergency, or other non-routine health services.

There were 336 million reported appointments in general practices in 2022-23 compared with 285.3 million reported in 2018-19 and 25.2 million A&E attendances in 2022-23, an increase of 3.6 million over the 21.6 million in 2011-12. The number of NHS staff has increased, including those working in unplanned or urgent care. The NHS’s funding continues to increase, with a total budget in 2022/23 of £152.6 billion. The NHS has not been able to secure the full benefits of increased spending and staff numbers, and productivity has fallen since the onset of the COVID-19 pandemic.

Performance against operational standards, and more widely, has deteriorated further since the onset of the COVID-19 pandemic. Ambulance response times for Category 2, 3 and 4 incidents (fig. 13 in the report) rose after February 2021, and reached record highs in December 2022, before falling in the first months of 2023. The number of ambulance patient handovers to A&E exceeding 30 minutes began increasing in 2021-22, peaking in December 2022 at 118,692, before falling to 90,998 in March 2023 (equivalent to 25.9% of all ambulance handovers). Numbers of 111 calls answered within 60 seconds remained relatively constant between 2014-15 and 2020-21 at between 11.2 and 13.3 million each year, despite increasing call volumes, but fell sharply to 8.4 million in 2021-22 and then 8.1 million in 2022-23.

Patient satisfaction with GP appointment times reached their lowest levels in 2022, and positive satisfaction rates with 111 fell from an average of 88.8% between 2011-12 and 2020-21 to 78.7% in 2021-22.

Overall, performance of the unplanned and urgent care system has been worsened by delays transferring patients from one service to another. There are multiple dependencies affecting the performance of unplanned and urgent care services. For example:

  • Delays in discharging patients when they are medically fit to leave hospital reduces available bed capacity, which slows admissions from emergency departments. The number of A&E patients waiting longer than four hours for admission to wards following a decision to admit reached an all-time high in December 2022 at 170,121.
  • More patients waiting longer in A&E departments has limited ambulance services’ capacity to transfer patients, and ambulance handovers exceeding 30 mins reached 74,473 in February 2023 compared with 47,480 in February 2018.
  • Longer handover delays in turn reduced ambulance services’ ability to attend new incidents and response times have deteriorated. Average ambulance response times for Category 2 incidents exceeded 39 minutes in March 2023 compared with just under 28 minutes in March 2018.

There is considerable variation in service performance and access, both between regions and between different providers. Ambulance response times for Category 1 incidents vary significantly, with an average time of 6 minutes 51 seconds for the London ambulance service in 2021-22, compared with 10 minutes 20 seconds for the South-West ambulance service. Response times for answering 999 calls similarly vary, with an average time of 5.4 seconds for the West Midlands ambulance service in 2021-22, compared with 67.4 seconds for the South-West ambulance service.

Earlier this year NHS England published a two-year plan, with more than £2.5 billion of funding, which aims to improve patient experiences across urgent and emergency care services by increasing capacity; growing the workforce; improving discharge; joining up care outside of hospitals, and making it easier to access the right care first time.

“More people than ever before are receiving unplanned and urgent care, with NHS England spending increasing amounts of public money and employing record numbers of people.

“Yet patients' satisfaction and access to services have been worsening, suggesting there is no single, straightforward solution to improving a complex and interdependent system.

“While NHS England has a plan to improve services, long-term trends in workforce, activity, spending and performance indicate this will be a significant challenge.”

Gareth Davies, head of the NAO

Read the full report

Access to unplanned or urgent care

Notes for editors

  1. ‘Category 1’ ambulance incidents refer to the most serious life-threatening conditions.
  2. ‘Category 2’ ambulance incidents refer to serious conditions, such as stroke, which may require urgent transport to hospital.
  3. ‘Category 3’ ambulance incidents refer to urgent but less serious problems requiring transport to an acute setting.
  4. ‘Category 4’ ambulance incidents refer to stable clinical cases still requiring transport to hospital or a clinic.

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