© National Audit Office 2023

Access to unplanned or urgent care

Department of Health & Social Care

Session 2022-23
21 June 2023
HC 1511

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Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 19 June 2023

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Gareth Davies
Comptroller and Auditor General
National Audit Office

16 June 2023

HC 1511 | £10.00

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The National Audit Office study team consisted of:

Dounia Foster-Hall, Eleanor Murray, Stephen Naulls, David Raraty, Ian Wang and Freddie Wong under the direction of Ashley McDougall and Robert White.

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Key facts

Summary

1 NHS services have been under increasing pressure in recent years, particularly since the start of the COVID-19 pandemic. We have previously reported on the NHS’s efforts to tackle the backlogs in elective care and its progress with improving mental health services in England. This report gives a factual overview of NHS services that may be used when people need rapid access to urgent, emergency, or other non-routine health services, and whether such services are meeting the performance standards the NHS has told patients they have a right to expect. It covers:

general practice;

community pharmacy;

111 calls;

ambulance services (including 999 calls);

urgent treatment centres; and

accident and emergency (A&E) departments.

2 There were close to half a billion patient interactions across these services in 2021-22, with a total estimated annual cost of some £21.5 billion a year.

3 In January 2023, the government and NHS England (NHSE) published a two-year delivery plan to reduce waiting times and improve patients’ experiences of urgent and emergency care services. It is too soon to assess whether this plan is working, but the first indication will be how well the NHS copes with winter 2023-24 pressures on services. Specialist services such as optometry, dentistry, paediatrics, and tertiary care are outside the scope of this report. NHSE considers that the combination of StrepA, influenza and COVID-19 in winter 2022-23 significantly exacerbated the challenges it already faced. We have not sought to isolate or quantify the impact of these factors.

Key findings

Demand

4 Population changes are contributing to increasing demand for healthcare. The likelihood of being disabled or experiencing multiple chronic and complex health conditions increases with age. People are living longer, with the population of England aged 65 or older increasing by 20.1% between 2011 and 2021 to 10.4 million people. Increasing numbers of people live with multiple long-term conditions and complex health needs. There were 8.5 million NHS hospital patients aged 65 and over in 2021-22, compared with 7.0 million in 2012-13. Academic research published in 2021 estimated that, in 2019, 52.8% of all adults in England had more than one long-term health condition, compared with 30.8% in 2004 (paragraphs 1.6 and 1.7).

5 Demand for unplanned or urgent care is increasing. In primary care, there were 336.0 million appointments in general practices in 2022-23 compared with 285.3 million in 2018-19, and monthly appointments recently reached record levels with 32.0 million provided in October 2022 compared with 27.1 million in October 2018. Community pharmacists also carried out an estimated 65 million consultations in 2022 compared with 58 million in 2021. For the most urgent pathways, annual calls to 111 increased by 9.5 million between 2014-15 and 2022-23, from 12.9 million to 22.3 million, and monthly calls peaked at a record 2.9 million in December 2022. Ambulance control rooms took 13.2 million calls in 2022-23 compared with 11.7 million in 2018-19, resulting in a record 101,089 Category 1 callouts in December 2022. There were 25.2 million A&E attendances in 2022-23, an increase of 3.6 million compared with the 21.6 million in 2011-12, peaking at a record 2.3 million attendances in December 2022 (paragraphs 2.7, 2.16, 3.4, 3.6 and 3.18, and Figure 9 and Figure 16).

NHS capacity

6 The number of general and acute hospital beds has increased slightly following a downward trend before the COVID-19 pandemic, but occupancy rates have also risen and patients are now staying longer in hospital compared with previous years. General and acute hospital bed capacity had been on a long-term downward trend since 2010 and, after allowing for COVID-19 restrictions, reached a low of 92,559 during the early stages of the pandemic. Bed numbers have since risen, but only back to pre-pandemic levels at 104,543 in Q4 2022-23, with occupancy rates for these beds at record levels (92.3% in Q4 2022-23). Higher levels of bed occupancy can increase the risk of bed shortages, periodic bed crises and increased numbers of hospital-acquired infections. Critical care patients are also staying longer in hospitals, with the average length of stay increasing from 4.0 days in 2017-18 to 4.8 days in 2021-22. The average number of patients remaining in hospital despite no longer needing to increased to 13,623 across Q4 of 2022-23, up by 1,505 (12%) compared with the same period in 2021-22 (paragraphs 1.9, 1.12 and 1.13, and Figure 2).

7 The number of NHS staff has increased, including those working in unplanned or urgent care. Full-time equivalent staff in the NHS workforce increased by 32.4% from the most recent low of 963,471 in June 2013 to an all-time high of 1,275,354 in February 2023. The numbers of GPs, ambulance staff and doctors in emergency departments have all increased in recent years (paragraphs 1.14, 2.12, 3.15 and 3.24, and Figure 3, Figure 8, Figure 15 and Figure 20).

8 The number of staff vacancies across the NHS rose from the start of 2021 but has recently fallen. Vacancies reached a low of 76,084 full-time equivalent staff in Q4 2020-21, before steadily rising to a high of 131,596 in Q2 2022-23 and falling to 112,498 in Q4 2022-23. The greatest increases between the low in Q4 2020-21 and Q4 2022-23 related to the acute sector, where vacancies rose by 21,522, and for mental health roles, where vacancies rose by 10,176. The average rate of staff leaving across all ambulance trusts has increased, from 7.5% in 2010-11 to 8.4% in 2020-21, and 42.9% of ambulance staff in the 2022 NHS staff survey said they often think about leaving their organisations. A survey of GPs carried out by the Royal College of GPs in 2022 found that 39% of respondents were considering leaving their profession within five years. In 2020, the government committed to providing 6,000 additional GPs but has since stated that achieving this is unlikely. NHSE has said it will publish a long-term workforce plan in 2023, setting out its workforce challenges and actions to address them. We, and the Committee of Public Accounts, have previously noted there have been repeated delays to the publication of NHSE’s long-term workforce plans (paragraphs 1.15, 2.14, 3.15 and 4.10, and Figure 4).

9 Spending on the NHS continues to increase. The total budget for NHSE in 2022-23 was £152.6 billion, some £28.4 billion more than in 2016-17 at 2022-23 prices. We estimate that NHSE’s spending on providing the services for unplanned or urgent care covered in this report is some £21.5 billion per year. The cost of different services ranges widely. We estimate that, in 2020-21, ambulance incidents cost £2.6 billion, emergency departments £4.6 billion, and general practices £12.6 billion (paragraph 1.2 and Figure 1).

Performance

10 Patients’ access to services for unplanned or urgent care has worsened. The mean time taken to answer ambulance-related 999 calls in March 2018 was 14 seconds, but this had increased to a high of 88 seconds in December 2022, and was 17 seconds in March 2023. The mean ambulance response time for Category 2 incidents was 39 minutes 33 seconds in March 2023, compared with 27 minutes 44 seconds in March 2018. In March 2023, 57% of patients in Type 1 A&E departments were admitted, transferred or discharged within four hours of their arrival, compared with 95% in March 2011. In December 2022, 711,881 A&E patients waited over four hours from their arrival to be admitted, transferred or discharged, an all-time high (paragraphs 3.8, 3.11 and 3.20, and Figure 12, Figure 13 and Figure 18).

11 There is considerable variation in service performance and access, both between regions and between different providers. In March 2023, proportions of Type 1 A&E patients being admitted, transferred or discharged within four hours of arrival varied from 53.3% in the Midlands to 62.1% in the South-East. Ambulance response times for Category 1 incidents vary significantly, with a mean 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 in 2021-22 of 5.4 seconds for the West Midlands ambulance service, compared with 67.4 seconds for the South-West ambulance service. The number of patients per GP in different Integrated Care Systems varied between 1,430 and 2,198 (paragraphs 2.13, 3.9, 3.12 and 3.21).

12 COVID-19 had, and continues to have, an adverse impact on the NHS’s capacity to meet healthcare needs. A proportion of NHS hospital beds are occupied due to COVID-19 cases, which rises and falls in line with wider infection rates. Absence rates in the NHS workforce have been higher following the pandemic than they were before. The average rate of absence between April 2009 and February 2020 was 4.2%, compared with 5.1% between March 2020 and October 2022, with the rate standing at 5.6% in October 2022. Measures in hospitals for COVID-19 infection control may also reduce the number of available beds and limit hospitals’ ability to move patients between wards in what could otherwise be the most efficient way (paragraphs 1.11 and 1.14).

13 The NHS has not met key operational standards for unplanned or urgent care since before the pandemic. The last time the NHS met its target for 95% of A&E patients to be admitted, transferred or discharged within four hours of arrival was in July 2015. Data to show performance against the NHS’s target that no ambulance handovers should take longer than 30 minutes have been available from November 2017. The target has not been met throughout that time, with 25.9% of handovers exceeding this threshold in March 2023 (paragraphs 3.14 and 3.20, and Figure 14).

14 Performance against operational standards, and more widely, has deteriorated further since the onset of the pandemic. Numbers of 111 calls answered within 60 seconds remained relatively constant between 2014-15 and 2020-21 at around 11 million to 13 million each year, despite increasing call volumes, but fell sharply to 8.4 million in 2021-22 and 8.1 million in 2022-23. Ambulance response times for Category 2, 3 and 4 incidents rose after February 2021, and ambulance handovers exceeding 30 minutes began increasing in 2021-22, peaking in December 2022 at 118,692, before falling and standing at 90,998 in March 2023. Numbers of A&E patients waiting longer than 12 hours to be admitted to a ward began rising rapidly in May 2021 and were at record levels in December 2022, before starting to fall. Patient satisfaction with general practice appointment times reached their lowest levels over the last five years in 2022 and positive satisfaction rates with 111 also fell from an average of 88.8% between 2011-12 and 2020-21, to 78.7% in 2021-22 (paragraphs 2.11, 3.4, 3.11, 3.13, 3.14 and 3.22, and Figure 7, Figure 9, Figure 13, Figure 14 and Figure 19).

15 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 between unplanned and urgent care services. For example, challenges 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. This then reduces ambulance capacity and therefore the timeliness of ambulance responses. Numbers 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 handovers exceeding 30 minutes were 74,473 in February 2023 compared with 47,480 in February 2018. Longer handover delays have in turn reduced ambulance services’ ability to attend new incidents and response times have deteriorated, with the mean times for responding to Category 2, 3 and 4 incidents at record highs in December 2022. While the NHS measures the performance of individual services, it does not currently have an overall measure capturing patient flows across its services or dependencies between services (paragraphs 1.8, 3.11, 3.14 and 3.22, and Figure 13, Figure 14 and Figure 19).

16 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. Analysis published by the Centre for Health Economics in 2020 concluded that, from 2004-05 to 2017-18, NHS productivity increased by 18% and that since 2009-10 NHS productivity growth had improved substantially faster than the overall economy. However, across 2019-20 and 2020-21, covering the onset of the COVID-19 pandemic, the Centre calculated that NHS productivity decreased by 23%, a reduction not echoed by a similar decline in the wider UK economy. It attributed this to overall NHS output decreasing by 16.1%, when adjusted for quality, and NHS inputs growing by 9.0%, when measured using a combination of direct and indirect inputs. The NHS recognises that it continues to face productivity challenges, some a direct result of the pandemic, such as increased staff absences and infection control measures. Other factors NHSE identified include a reduced willingness by staff to offer discretionary overtime and an increase in delayed discharges (paragraphs 4.11 to 4.13).

17 NHSE has a plan to reduce waiting times and improve patients’ experiences. In January 2023, the government and NHSE published a two-year urgent and emergency care recovery plan. The plan focusses on increasing capacity, workforce growth, improving discharge, joining up care outside of hospitals, and improving access, and is accompanied by more than £2.5 billion of funding together with a commitment to publish more performance data to improve transparency. The recovery plan sets interim ambitions for key operational standards, which will apply for 2023-24 only, to monitor progress in returning performance to expected levels. This includes ambitions for the percentage of A&E patients to be admitted, transferred or discharged within four hours to be 76% by March 2024 (compared with a standard of 95%), and for Category 2 ambulance response times to be 30 minutes on average (compared with a standard of 18 minutes). In May 2023, the Department of Health & Social Care (DHSC) and NHSE published a Delivery plan for recovering access to primary care, with key ambitions to improve patients’ contact with GP practices and improve patients’ information about how requests to their GPs would be managed (paragraphs 4.4 and 4.6 to 4.9).

Concluding remarks

18 More people than ever before are receiving unplanned and urgent NHS care every day. To support these services, the NHS is spending increasing amounts of public money and employing record numbers of people. Nevertheless, patients’ satisfaction and access to services have been worsening, suggesting there is no single, straightforward solution to improving what is a complex and interdependent system. NHSE’s recovery plan for urgent and emergency care aims to improve services by March 2024. The long-term trends in workforce, activity, spending and performance indicate this will be a significant challenge.

19 The rest of this report sets out:

how the NHS provides unplanned and urgent care;

services for unplanned incidents, including primary and community care;

services for urgent incidents, including emergency care; and

NHSE’s plans for improving these services.

Part One

How the NHS provides unplanned or urgent care

National responsibility for health services

1.1 The Department of Health & Social Care (DHSC) is responsible for overall health policy in England. NHS England (NHSE) is an arm’s-length body of the DHSC and leads the National Health Service (NHS). NHSE manages the budgeting, planning, and delivery of health services in England, including overseeing their commissioning, either directly or through delegated arrangements with local Integrated Care Boards.

1.2 NHSE had a total budget of £152.6 billion for 2022-23, some £28.4 billion more than its budget in 2016-17 at 2022-23 prices.

Services for unplanned or urgent care

1.3 Figure 1 shows the six key NHS services providing unplanned or urgent care, the volume of work they handle, the cost of services, and commissioning arrangements. The individual elements are dependent on each other, and on external constraints, to work most effectively. For example, delays in ambulance handovers may affect ambulance response times but are in turn affected by the rate at which accident and emergency (A&E) departments can admit or discharge attendees. The pace of emergency admissions is affected by hospitals’ ability to discharge patients when medically fit. We consider performance of the different elements of the systems in Parts Two and Three. This Part of the report sets out some of the background influences on the unplanned and urgent care systems, including:

demographics;

funding;

hospital bed capacity;

delayed discharge of patients from hospitals;

overall NHS workforce numbers; and

NHS performance standards.

Patient pathways

1.4 Different NHS services provide:

advice or information (for example, community pharmacies, general practices and 111);

triage, assessment or referral for treatment later (for example, general practices and 111); or

immediate treatment (for example, 111, 999, ambulances, A&E and Urgent Treatment Centres).

1.5 In practice, most services provide a combination of all three options for patients. General practices and NHS 111, for example, both offer patients advice and information or assessment, and they may refer patients for further assessment and treatment.

The context for the performance of urgent and unplanned NHS services

Demographics

1.6 The likelihood of being disabled and/or experiencing multiple chronic and complex health conditions increases with age. The population of England is ageing. In 2021, there were 10.4 million people in England aged 65 and over, compared with 8.7 million in 2011, a rise of 20.1%. This meant the proportion of the population aged 65 or over increased from 16.3% to 18.4% during this period.

1.7 Recent evidence has highlighted how population health needs in England have become more complex during the past 10 years.

NHSE reports that there is an increasing need for healthcare because of a growing, ageing population and greater numbers of people living with multiple long-term conditions.

There were 8.5 million NHS hospital patients aged 65 and over in 2021-22 compared with 7.0 million in 2012-13, with this cohort reaching 9.0 million in 2019-20. The mean age of patients increased from 52.0 years to 54.6 years over the same period.

Academic research published in 2021 estimated that 52.8% of all adults in England were living with more than one long-term condition in 2019, compared with 30.8% in 2004.

In March 2023, 7.3 million people were on a waiting list for elective care, which can result in more people accessing other NHS services.

NHS hospital bed capacity

1.8 Increasing demand for health care places greater pressure on hospital beds. The number of available beds is important because different NHS services work together as an overall system.

If there are not enough beds available, patients arriving from other parts of the system, such as ambulance services or A&E departments, cannot be assigned a bed for treatment.

This slows down the overall flow of patients and can create bottlenecks in other parts of the system.

NHSE currently does not have an overall measure to capture patient flows across its services.

The following section looks at factors affecting hospital bed capacity, including recent trends in bed availability and occupation rates, numbers of long stay patients, and delayed discharges from hospitals.

Hospital beds and occupancy rates

1.9 The number of general and acute (G&A) beds in NHS hospitals had been on a downward trend until 2020, decreasing from 110,568 in Q1 2010-11 to 102,194 in Q4 2019-20, a reduction of 7.6% (Figure 2).

G&A bed capacity, after allowing for COVID-19 restrictions, fell significantly at the start of the pandemic, reaching a low of 92,559 beds in Q1 2020-21. It has steadily increased since, but only returned to just above pre-pandemic levels from the start of 2022-23, standing at 104,543 in Q4 2022-23.

The proportion of G&A beds that are occupied had been rising prior to the pandemic, increasing from an average of 87.1% throughout 2010-11 to 90.2% for 2019-20. Quarterly occupancy rates fell to 63.1% during the pandemic but have gradually increased, with the 92.3% recorded in Q4 2022-23 representing record levels.

Higher levels of bed occupancy can increase the risk of bed shortages, periodic bed crises and increased numbers of hospital-acquired infections.1 NHSE considers that, on a national level, a 92% bed occupancy rate is the tipping point beyond which A&E performance can be seriously affected.

1.10 To provide better support for patients experiencing mental health crisis, since 2019 local areas have received funding to develop provision of alternatives to A&E or psychiatric admission, such as crisis cafes and safe haven spaces. Our recent report on mental health services showed that there had been progress in improving provision of 24-hour, seven days a week, crisis and liaison mental health services, but also highlighted the need to improve data on service demand, capacity, activity and patient outcomes.2

1.11 A proportion of occupied beds in NHS hospitals relate to patients who were admitted with COVID-19, the number of which has fluctuated with changes in infection rates.

The number of NHS hospital beds occupied by patients admitted with COVID-19 peaked at 34,336 in January 2021, equivalent to 29.6% of occupied beds at the time.

The most recent data available at the time of our fieldwork, for 6 April 2023, showed that there were 6,829 beds occupied by patients admitted with COVID-19, representing 5.3% of occupied beds.

Measures in hospitals for COVID-19 infection control may also reduce bed availability for non-COVID-19 patients, and limit hospitals’ ability to move patients between wards in what could otherwise be the most efficient way.

Length of stay

1.12 The time patients spend in acute hospital beds affects hospitals’ capacity to admit new patients. Longer average stays will reduce the number of new patients that can be admitted.

Mean lengths of stay for hospital patients decreased from 5.3 days in 2011-12 to 4.4 days in 2021-22.

However, lengths of stay for critical care patients have increased in recent years, from 4.0 days in 2017-18 to 4.8 days in 2021-22.

The number of long-stay patients has increased. At the start of March 2019, there were 40,100 patients staying longer than seven days and 15,536 staying longer than 21 days. At the start of March 2023, this had increased to 49,531 for those staying longer than seven days (a rise of 24%), and 19,367 for those staying longer than 21 days (a rise of 25%).

Hospital discharges

1.13 A significant influence on hospital bed capacity is the extent to which patients who are medically fit for discharge can, in practice, leave hospital as soon as they are ready, freeing up bed space for others. Numbers of patients remaining in hospital despite no longer needing to averaged 13,623 across Q4 of 2022-23, up 1,505 (12.4%) compared with 12,118 during the same period in 2021-22. Limited capacity in NHS community services, private nursing homes or care homes, or the availability of home care support can contribute to patients remaining in hospitals unnecessarily.

NHS workforce

Full-time equivalent staff

1.14 The number of NHS full-time equivalent (FTE) staff has steadily grown during the past 10 years, from the most recent low of 963,471 in June 2013 to an all-time high of 1,275,354 in February 2023, a rise of 32.4% (Figure 3). However, absence rates in the NHS due to sickness have been much higher since the start of the pandemic, compared with the preceding 10 years. The average rate of absence between April 2009 and February 2020 was 4.2%, compared with 5.1% between March 2020 and October 2022, with the rate standing at 5.6% in October 2022. The NHS also faced industrial action between December 2022 and May 2023 which has had an impact on capacity.

Vacancies

1.15 Increasing NHS workforce numbers do not provide a full measure of the NHS’s capacity to meet need. Despite continuous workforce growth, vacancies across the NHS have been increasing until very recently.

Total vacancies were 110,281 FTE staff in Q1 2018-19. They had fallen to a low of 76,084 by Q4 2020-21 but steadily rose to an all-time high of 131,596 in Q2 2022-23, an increase of 55,512 (Figure 4). Vacancies have since decreased and stood at 112,498 in Q4 2022-23.

The largest increases in vacancy numbers (absolute FTE staff), between the low in Q4 2020-21 and Q4 2022-23, have been for acute care (21,522 higher) and mental health roles (10,176 higher). We reported in February 2023 that between 2016-17 and 2021-22 the mental health workforce had increased by 22%, to 133,000 FTE staff, but despite this increase staff shortages remained the major constraint to improving and expanding mental health services.3

Over the same period, between Q4 2020-21 and Q4 2022-23, ambulance services’ vacancies nearly tripled from 1,080 to 3,060 and community vacancies increased from 2,957 to 4,772.

Performance standards

1.16 NHS service providers have specific performance indicators and operational standards set out in their contracts with NHSE. For commissioners of non-primary care services, the NHS standard contract specifies national quality requirements for A&E waiting times, ambulance response and handover times, and urgent community health service response. Figure 5 sets out key performance indicators and operational standards relevant to the NHS services reviewed in this report. There are currently no waiting time targets for GP services, although the government’s September 2022 Plan for Patients set out an expectation that all patients needing an appointment within two weeks would be able to get one.

1 Comptroller and Auditor General, Emergency admissions to hospital: managing the demand, Session 2013-14, HC 739, National Audit Office, October 2013.

2 Comptroller and Auditor General, Progress in improving mental health services in England, Session 2022-23, HC 1082, National Audit Office, February 2023.

3 See footnote 2.

Part Two

NHS services for unplanned incidents

2.1 This part of the report looks at NHS services for unplanned incidents. For the purposes of this report, we have included services, most commonly in the community, which a patient may consider where immediate treatment is not necessarily sought. These services generally offer a combination of advice and information, and triage or assessment, and patients may be referred for further treatment.

2.2 The NHS services reviewed in this part of the report are:

community health services;

general practices; and

community pharmacies.

Primary care

2.3 Primary care comprises general practices, dentists, opticians and community pharmacists, and often serves as the first point of contact for people into the wider NHS. Community health services are increasingly viewed as essential to primary care, and the NHS Long Term Plan set out aims to reduce the historic separation that existed between them. Since the Plan was published in 2019, GP practices have been coming together to form around 1,250 Primary Care Networks across England. These networks have then joined with local community, social care, pharmacy, mental health and other services, aiming to provide fully integrated community-based health care for their local populations.

Community health services

2.4 Community health services can cover a wide range of different provisions, depending on the needs of local areas. These services could include district nursing, fall prevention and health visiting, and are often provided by NHS organisations working in partnership with local authorities, community groups, and independent providers. Effective community health services can help support the discharge of patients who are ready to leave hospitals.

2.5 Community health services also include urgent community response teams providing urgent care in people’s homes and care homes to reduce avoidable hospital admissions and ambulance call-outs. Since April 2022, NHS England’s (NHSE’s) operational standards have set a requirement for urgent community response services to deliver care within two hours of receiving a referral, with a minimum threshold of reaching 70% of patients in crisis in under two hours to be achieved by the end of December 2022. These referrals recently peaked in December 2022 at 38,175, of which 79% met the two-hour standard. The most recent provisional data at the time of our report for March 2023 showed 33,375 referrals, of which 81% met the two-hour standard. NHSE aims to increase urgent community response referrals, particularly those received from ambulance services. In March 2023, 18.7% of referrals were from GP practices and 8.7% were from ambulance services.

GP practices

2.6 As of March 2023, there were 6,442 GP practices in England providing advice and treatment for many medical conditions, as well as referrals to other parts of the NHS for more specialist treatment. Patients can book appointments in general practice by telephone or online via the NHS website or NHS App. Different practices adopt varying approaches for booking urgent appointments.

Appointments in general practice

2.7 NHSE began reporting numbers of appointments in general practice from November 2017.4 Not all practices submit data, and so NHSE publishes actual reported numbers of appointments alongside an extrapolated estimate of the total number of appointments in all practices. At the start of reporting in November 2017, NHSE reported 24.8 million actual appointments and estimated there were 28.0 million total appointments. The most recent data at the time of our fieldwork for March 2023 reported 31.4 million actual appointments, from which NHSE estimated there were 31.6 million total appointments.

In 2018-19 there were 285.3 million actual reported appointments compared with 336.0 million in 2022-23.

There was a sharp fall in demand coinciding with the early stages of the COVID-19 pandemic. In 2019-20, general practices provided an average of 25.1 million appointments each month. Appointments then decreased during the early stages of the pandemic, with fewer than 16 million provided in April 2020.

Monthly appointment numbers have fluctuated since then, peaking at an all-time high of 32.0 million in October 2022 (for comparison, there were 27.1 million appointments in October 2018). The most recent data for March 2023 shows appointments were close to the record high at 31.4 million.

Times between booking and appointment in general practice

2.8 In the 12 months before the pandemic, between April 2019 and March 2020, on average 41.7% of GP patients got an appointment on the same day they booked (Figure 6).

Following the onset of the COVID-19 pandemic, the proportion seen the same day increased to 63.3% in April 2020, but has now returned closer to pre-pandemic levels, with 43.2% seen in March 2023.

The proportion of patients waiting more than 28 days has decreased following the pandemic, from 5.1% in 2019-20 to 4.2% in 2022-23.

2.9 Public satisfaction with general practice appointment times captured through the GP Patient Survey reached its lowest levels in 2022.

Just over half of patients surveyed in 2022 (55.2%) were satisfied with their appointment time compared with nearly two-thirds (65.9%) in 2018.

Dissatisfaction rates increased 6.6 percentage points to 23.5% over the same period.

There are currently no formal performance targets related to GP appointments, but there is an expectation that patients with clinically urgent needs should be assessed on the same day and for an appointment to be scheduled within two weeks if the need is not urgent.

The ways people consult GPs

2.10 The way general practice appointments are carried out has changed significantly since the start of the pandemic.

In the 12 months before the outbreak of COVID-19, 80.0% of appointments were face-to-face and 14.3% of appointments were delivered virtually or via telephone (the rest were home visits or unknown).

For the 12 months from March 2020, the proportion of face-to-face appointments decreased to 54.1% and the proportion of virtual and telephone appointments rose to 41.2%.

As of March 2023, the proportion of telephone and virtual appointments had dropped to 27.4%, and GP practices are now seeing increasing proportions of patients in person.

2.11 In 2022, GP Patient Survey satisfaction rates for appointments offered were the lowest they had been in five years (71.9%) (Figure 7).

However, more patients accepted appointments in 2022 (96.1%) compared with before the pandemic (94.2% in 2018).

In 2022, of those who were not offered an appointment or did not accept one that was offered, the main reasons cited for not accepting an appointment were none being available for the preferred time of day (27.6%), or that patients could not book ahead at their GP practice (22.7%).

When those not offered an appointment, or who declined the offer of one, were asked what course of action they subsequently took, the most common responses were 34.3% reported not seeing or speaking to anyone else, 14.3% contacted their practice at another time, and 11.3% spoke to their pharmacist.

General practice workforce

2.12 The number of GPs, measured in full-time equivalents, grew from 34,464 in March 2017 to 36,428 in March 2023, an increase of 5.7% (Figure 8).

Numbers of qualified permanent GPs have fallen throughout this period, decreasing by 5.3% from 28,143 to 26,665.

Numbers of trainee GPs began increasing from the start of 2020-21 and they will typically take three years to complete their training.

The number of patients registered with GPs increased by 6.0% between November 2017 (the earliest available data) and March 2023.

2.13 The GP workforce served a total of 62.4 million registered patients in March 2023. However, there is significant variation in the numbers of patients per GP, with GPs in one Integrated Care System (ICS) responsible for around 2,198 patients each, compared with 1,430 each in the ICS with the lowest number.

2.14 In 2020, the government committed £1.5 billion for additional staff in general practice alongside an aim to increase GP numbers by 6,000 but has since stated that achieving this target is unlikely. A survey of GPs carried out by the Royal College of GPs in 2022 found that 39% of respondents were considering leaving their profession within five years.

2.15 The workforce model in general practice is changing. In 2019, NHSE introduced the Additional Roles Reimbursement Scheme which allowed Primary Care Networks to claim reimbursement for the salaries, and some costs, of selected multidisciplinary roles in local communities. NHSE reported there were an additional 29,103 full-time equivalents in direct patient care roles due to the scheme in March 2023, compared with March 2019.

Community pharmacies

2.16 Community pharmacies are in places such as high streets, supermarkets and community centres, and many are open late or during weekends. People do not need an appointment to see a community pharmacist and may be referred to one after first contacting 111 or their GP.

There were 11,522 community pharmacies in England in 2021-22, a slight decline on the 11,949 in 2015-16.

In 2022, community pharmacists carried out an estimated 65 million consultations, seven million more than the 58 million in 2021.

2.17 Community pharmacies can advise and provide medicines and treatment for minor illnesses, or direct patients to other services for more serious conditions. NHSE’s contract framework for community pharmacists specifies advising patients about self-care and healthy living as a minimum service requirement. However, NHSE does not currently collect data on the amount of advice community pharmacists provide.

2.18 An IPSOS survey in September 2022 found community pharmacies were the organisations the public would most likely go to for information or advice about medicines or minor conditions. Furthermore, this advice is regarded very positively, with 91% of respondents receiving community pharmacy advice in the previous year rating this as good.

2.19 Since 2019, almost all community pharmacies have also participated in the Community Pharmacist Consultation Service. Under this scheme, community pharmacists provide patients from other parts of the NHS with a same day appointment for a minor illness or urgent medical supply, to relieve pressure on GPs and accident and emergency (A&E) departments. Use of the Community Pharmacist Consultation Service recently peaked with around 159,000 referrals in December 2022, compared with 61,600 in February 2022, and the cost of providing the service in 2021-22 was £11.6 million.

4 COVID-19 vaccination appointments have been excluded from the dataset from December 2020 onwards.

Part Three

NHS services for urgent incidents

3.1 This part of the report looks at the accessibility and performance of NHS services involved in responding to situations where individuals are seeking an immediate response or treatment.

3.2 The NHS services reviewed in this part are:

NHS 111;

ambulance services, including 999; and

accident and emergency departments.

NHS 111

3.3 NHS 111 is intended for urgent medical or health issues that are not life-threatening and people can visit 111 online or phone the 111 service at any time for free. Calls are first assessed by trained call handlers and a course of action is then recommended to the caller, which may involve referral to clinicians such as doctors and nurses, pharmacists or paramedics. The 111 service will provide advice and information if that is all the patient needs, but it can also book patients into other parts of the NHS, such as with GPs, ambulance services and accident and emergency (A&E) departments. Patients experiencing a mental health crisis can access emergency treatment through NHS urgent mental health helplines and 24-hour, seven days a week local crisis services. Referrals to these crisis services can also be provided through NHS 111, with NHS England (NHSE) aiming to provide universal access to crisis services for all ages through 111 by the end of 2023-24.

111 call volumes and response times

3.4 Calls to NHS 111 increased by 9.5 million between 2014-15 and 2022-23, from 12.9 million to 22.3 million (Figure 9).

The number of monthly 111 calls peaked at a record 2.9 million in December 2022.

The number of calls answered within 60 seconds stayed relatively constant at between 11.2 million and 13.3 million, despite increasing call volumes, until falling to 8.4 million in 2021-22 and then 8.1 million in 2022-23.

The percentage of answered calls that were answered within 60 seconds decreased from 92.1% in 2014-15 to 79.8% in 2020-21, before falling significantly to 47.3% in 2021-22.

Positive satisfaction rates with NHS 111 averaged 88.8% between 2011-12 and 2020-21, standing at 88.0% at the end of this period but falling to 78.7% in 2021-22.

111 call outcomes

3.5 The balance of outcomes from 111 calls has changed since 2010-11.

The proportion of responses advising callers to attend primary care or community care services decreased from 59.4% in 2010-11 to 51.9% in 2020-21 (Figure 10).

An increasing proportion of people are now being advised to attend A&E (increasing from 6.6% to 10.5%) or another service (increasing from 5.2% to 9.3%) during the same period.

Calls resulting in ambulance dispatches have fluctuated between 10.7% and 13.3% since 2010-11.

Ambulance services

Control room volumes

3.6 Requests for ambulance services are coordinated by ambulance control rooms and demand has increased in recent years. Calls to control rooms include those transferred from 999, 111 and 112 lines, and from other emergency and rescue services and healthcare professionals.

There were 13.2 million calls to control rooms in 2022-23, 1.5 million more than the 11.7 million in 2018-19, with a previous high of 14.1 million seen in 2021-22.

Between April 2018 and March 2020, there were around one million calls each month to ambulance control rooms (Figure 11).

Calls fell to 836,000 in May 2020 but then started rising and have generally been above 1.1 million since May 2021, apart from January and February 2023 when they dropped below 930,000.

The most recent figures show there were 1.1 million calls in March 2023.

Time to answer 999 calls

3.7 A significant proportion of calls to ambulance control rooms are from 999, with the number of 999 calls answered typically representing around three-quarters of all calls made.

3.8 For the two years prior to the onset of the COVID-19 pandemic, the mean time to answer 999 calls related to health issues was around nine to 10 seconds (Figure 12).

The mean answer time increased to 49 seconds at the start of the pandemic in March 2020, but quickly recovered to 11 seconds by April 2020. It peaked in December 2022 at 88 seconds, before falling sharply.

Mean answer times are now higher than before the pandemic, with a mean of 17 seconds in March 2023, compared with a mean of 14 seconds in March 2018.

3.9 There is variation in the time taken to answer 999 calls. The mean call answer time for the West Midlands ambulance trust in 2021-22 was 5.4 seconds, compared with 67.4 seconds for the South-West ambulance trust.

Ambulance incident volumes

3.10 Ambulance incidents include an ambulance being dispatched to take a patient to A&E or other destination for further treatment. However, they can also include other forms of care such as ‘See and Treat’, where an ambulance is dispatched and the patient is treated at the scene rather than being taken to hospital or elsewhere, and ‘Hear and Treat’, where an ambulance is not dispatched and patients receive clinical advice over the phone.

There were 8.1 million ambulance incidents in 2022-23, compared with 8.4 million in 2018-19.

The number of monthly incidents fluctuated at around 700,000 to 800,000 between 2017 and the first half of 2021, reaching a high of 800,221 in May 2021.

The number of patients taken to A&E averaged 383,452 a month in 2021-22 (or 51.9% of all incidents each month throughout the year) and 345,162 a month in 2022-23 (or 51.2% of all incidents each month throughout the year).

Ambulance incident response times

3.11 The Handbook to the NHS Constitution for England sets targets for ambulances to respond within seven minutes on average for the most serious Category 1 incidents, which can involve life-threatening conditions, and 18 minutes on average for Category 2 incidents.

Monthly Category 1 ambulance callouts were the highest on record at 101,089 in December 2022.

The mean response time for Category 1 incidents in March 2023 was 8 minutes 49 seconds, and for Category 2 incidents it was 39 minutes 33 seconds (Figure 13).

In March 2018, the mean Category 1 response time was 8 minutes 35 seconds and for Category 2, it was 27 minutes 44 seconds.

Category 1 response times have ranged between 6 minutes 31 seconds and 10 minutes 57 seconds since 2017. Response times for Category 2, 3 and 4 incidents rose after February 2021 and reached record highs in December 2022 before falling in the first months of 2023.

3.12 There is considerable variation in ambulance response times.

In 2021-22, the mean Category 1 incident response time for the London ambulance service was 6 minutes 51 seconds compared with 10 minutes 20 seconds for the South-West ambulance service.

In 2021-22, the mean Category 2 incident response time for the ambulance service in the Isle of Wight was 26 minutes 20 seconds, compared with 1 hour 1 minute 57 seconds for the South-West ambulance service.

3.13 In addition to targets for average ambulance response times, the NHS also has target times for which 90% of incidents should be responded to. Performance against these targets in March 2023, as reported by NHSE, was as follows:5

90% of Category 1 incidents should be responded to within 15 minutes. In March 2023, 90% of Category 1 emergencies were responded to within 15 minutes 38 seconds.

90% of Category 2 incidents should be responded to within 40 minutes. In March 2023, 90% of Category 2 incidents were responded to within 1 hour 26 minutes 15 seconds.

90% of Category 3 incidents should be responded to within two hours. In March 2023, 90% of Category 3 incidents were responded to within 5 hours 21 minutes 12 seconds.

90% of Category 4 incidents should be responded to within three hours. In March 2023, 90% of Category 4 incidents were responded to within 6 hours 54 minutes 22 seconds.

Ambulance handovers

3.14 Prior to 2022-23, NHSE’s target for handover of ambulance patients to A&E required no handovers to take longer than 30 minutes. Data against the 30-minute target are only available from November 2017 and the target has not been achieved since data collection began.

The number of patient handovers exceeding 30 minutes in March 2023 was 90,998, equivalent to 26% of all ambulance handovers.

Handovers exceeding 30 minutes began increasing in 2021-22, peaking in December 2022 with 118,692 across the month (Figure 14).

The percentage of handover times exceeding 30 minutes during the month of February has nearly doubled in the past five years, with 24% in February 2023 (74,473 handovers out of 316,623) compared with 13% in February 2018 (47,480 handovers out of 371,971).

In 2023, NHSE amended this target to require all handovers to take place within 60 minutes, and for no more than 5% to be delayed by 30 minutes or more.

Ambulance workforce

3.15 Between 2009 and 2013, numbers of NHS ambulance staff were consistently around 30,000, with a low of 29,550 in August 2012 (Figure 15).

Ambulance staff numbers began steadily rising from October 2014 onwards and reached 43,647 by October 2022. The most recent data for February 2023 show numbers had increased further to 44,289, representing a 49.9% increase from the low in August 2012.

Despite this growth, there are signs that ambulance staff are under pressure. The average rate of staff leaving across all ambulance trusts has increased, from 7.5% in 2010-11 to 8.4% in 2020-21, the first full year of the pandemic (these figures include staff leaving a trust and remaining in the NHS, and those leaving the NHS altogether). In 2022, 42.9% of ambulance trust staff responding to the NHS Staff Survey said they often think about leaving their organisations, compared with 39.7% in 2018.

Accident and emergency (A&E) departments

3.16 A&E departments are responsible for treating serious injuries and life-threatening emergencies. There are three main types of A&E department.

Type 1 departments are consultant-led services with full resuscitation facilities, typically treating the most serious incidents. There are around 170 Type 1 A&E departments in England.

Type 2 departments provide accident and emergency services for single specialist areas, such as eye care or dentistry.

Type 3 departments treat the least serious injuries or illnesses and are also known as Urgent Treatment Centres. They are usually GP- or nurse-led, open at least 12 hours a day, and can also allow appointments through 111 or GP referrals. Urgent Treatment Centres can be co-located with Type 1 emergency departments or situated in local communities.

3.17 Patients are taken to A&E in an ambulance, or they may walk in themselves. Patients are first assessed, and a decision is made to admit them, transfer them to another department or facility, or to discharge them from hospital.

Attendances at A&E

3.18 Monthly attendances at A&E departments had been steadily increasing since 2010.

In 2022-23, there were a total of 25.2 million attendances, compared with 21.6 million in 2011-12, an increase of 3.6 million (17%).

Monthly A&E attendances peaked at a record 2.3 million in December 2022.

There were 2.2 million monthly attendances during March 2023 compared with 1.9 million in March 2011, an increase of 0.3 million (14%) (Figure 16).

Attendances fell sharply during the COVID-19 pandemic but since the middle of 2021 have broadly returned to pre-pandemic levels.

Between 2010 and the start of 2020, attendances at Type 1 departments consistently accounted for around two-thirds of all attendances. The proportion of these attendances increased when the pandemic started, coinciding with the overall drop in A&E activity. They reached 75% in April 2020, but are now also back to pre-pandemic levels, standing at 63% in March 2023.

Admissions through A&E

3.19 Admissions through A&E are dominated by those from Type 1 departments, which consistently account for around 98% of all admissions.

Monthly admissions from Type 1 departments had been steadily increasing since 2010 at an average rate of around 1,138 per month (Figure 17).

Admissions peaked at 416,017 in December 2019 before dropping sharply at the start of the pandemic.

These admissions had returned to pre-pandemic levels by May 2021 but have since fallen and were at 381,682 in March 2023, lower than in the months leading up to the pandemic.

Waiting times for decisions in A&E

3.20 The Handbook to the NHS Constitution for England commits to a maximum four-hour wait for patients in A&E. This is reflected in NHSE’s operational standard for 95% of A&E patients to be admitted, transferred or discharged within four hours of arrival. This has not been achieved across all A&E departments since July 2015, with 71.5% meeting this standard in March 2023 (Figure 18). In the same month, 57% of patients in Type 1 departments were admitted, transferred or discharged within four hours of arrival, compared with 95% in March 2011. Across all A&E departments, the number of patients waiting longer than four hours reached record highs in December 2022 at 711,881 and stood at 550,538 in March 2023.

3.21 There is some variation at regional levels regarding the percentage of A&E patients admitted, transferred or discharged within four hours of their arrival.

Across all types of A&E departments, this ranged from 67.9% in the East of England to 75.9% in the South-East in March 2023.

For Type 1 departments, percentages varied from 53.3% in the Midlands to 62.1% in the South-East.

Waiting times for admission to wards from A&E

3.22 Since 2010, numbers of A&E patients waiting more than four hours to be admitted to a ward following a decision for admission have steadily increased, except for a steep drop in the early stages of the pandemic, and reached an all-time high of 170,121 in December 2022 (Figure 19). These numbers have since fallen and stood at 144,308 in March 2023. Numbers of patients waiting longer than 12 hours for admission began rising rapidly in May 2021 and stood at a record 54,573 in December 2022, before falling to 39,687 in March 2023.

3.23 NHSE has an operational standard for no A&E patient to wait longer than 12 hours to be admitted to a ward following a decision. For 2022-23, its planning guidance asked local systems to ensure no more than 2% of patients waited more than 12 hours between their arrival in A&E to either discharge, admission or transfer. As at the end of May 2023, NHSE does not publish data about lengths of waits beyond 12 hours, so the extent of patients waiting significantly longer than this threshold is unclear (for example, whether a patient waited 13 hours or 24 hours for admission following a decision to admit).

Doctors working in emergency departments

3.24 The numbers of doctors working in emergency medicine has doubled in the past 13 years, increasing from 4,835 in February 2010 to 9,595 in February 2023, a rise of 98% (Figure 20).

5 For ambulance targets relating to response times for 90% of calls, NHSE reports the time achieved by 90% of incidents and not the percentage of incidents where the response met the relevant standard.

Part Four

NHS England’s recovery plans

4.1 NHS England (NHSE) has recognised the need to address performance and access issues across services for urgent and unplanned care. This part of the report sets out the actions it has announced in recent years to improve these services. It comprises:

improvements in primary care;

the urgent and emergency care recovery plan; and

the NHS workforce plan.

4.2 The NHS Long Term Plan, published in 2019, provides the overall strategic context for the services described in this report. Since that date, the Department of Health & Social Care (DHSC) and NHSE have published plans covering primary care and urgent and emergency care, and committed to publish the NHS workforce plan.

Primary care

4.3 In November 2021, NHSE commissioned the Fuller Stocktake to set out a vision for integrating primary care and to improve access, experience, and outcomes for communities. The report was published in May 2022 and NHSE committed to several actions in response. These included:

a step-change in ambitions for preventative care through national and local health programmes and population-level interventions;

an improved model to deliver urgent and episodic care, including a single 24-hour, seven days a week point of contact incorporating a range of services from 111 to community pharmacies; and

changes to chronic disease management and complex care.

4.4 In May 2023, DHSC and NHSE published a Delivery plan for recovering access to primary care, setting out actions to improve access to primary care services. The plan has two key ambitions: to improve patients’ contact with their GP practices; and to improve patients’ information about how requests to their GPs will be managed. The plan will focus on four key areas in its first year.

Empowering patients to manage their own health, including through the NHS App, self-referral, and expanding community pharmacy.

Implementing the Modern General Practice Access model, which includes improvements to digital telephony, online requests, and assessment and response.

Building capacity to deliver more appointments from more staff and adding flexibility to the types of staff recruited and how they are deployed.

Cutting bureaucracy to improve the interface between primary and secondary care and reduce administrative burden for GPs.

4.5 To support the plan, DHSC and NHSE have re-targeted more than £1 billion of funding, including £240 million in 2023-24 for new technologies and support for Primary Care Networks, and up to £645 million between 2023-24 and 2024-25 to expand community pharmacy.

The urgent and emergency care recovery plan

4.6 In January 2023, the government and NHSE published a two-year urgent and emergency care recovery plan to reduce waiting times and improve patients’ experiences of using urgent and emergency care services. The plan states that recent pressures on these services have mainly been due to increasing demand alongside constraints on the ability to move or flow patients through the wider system.

4.7 The plan requires providers from not just the acute sector, but also wider community, primary care, social care and voluntary sectors, to come together and to work collaboratively. It is intended to last two years initially and focuses on five key areas:

increasing capacity;

growing the workforce;

improving discharge;

expanding and better joining-up health and care outside of hospitals; and

making it easier to access the right care first time.

4.8 The government will provide more than £2.5 billion as part of the recovery plan. This includes £1 billion to increase capacity in urgent and emergency care, £150 million capital funding for urgent mental health services, and £1.6 billion to support discharge into the most appropriate setting for patients. In June 2023, the government announced an additional £250 million for capital improvement schemes to support the plan.

4.9 The plan commits to publishing more data to improve transparency, such as on 12-hour accident and emergency (A&E) waits from time of arrival and on the performance of local services. The plan also notes interim targets for key operational standards, which will apply to 2023-24 only, to monitor progress in returning performance to expected levels. This includes ambitions for:

the percentage of A&E patients admitted, transferred, or discharged within four hours to be 76% by March 2024, compared with a standard of 95%; and

response times for Category 2 ambulance incidents to average 30 minutes during 2023-24, compared with a standard of 18 minutes, with further improvement the following year towards pre-pandemic levels.

NHSE began publishing data against 12-hour A&E waits in May 2023. This showed 8.2% of Type 1 A&E attendances in April 2023 waited longer than 12 hours from their arrival.

NHS workforce plan

4.10 The NHS workforce will be crucial to NHSE’s plans for all its services, including those for urgent and unplanned care. NHSE has committed to publishing a long-term workforce plan later in 2023 to set out the challenges facing the workforce and propose actions to address them. The plan will:

identify the number of staff needed across the country and set out workforce projections for groups and professions over the short, medium and long term;

detail actions to close workforce shortfalls; and

set out a view of increased workforce productivity and increasing capacity.

We and the Committee of Public Accounts have previously noted there have been repeated delays to the publication of NHSE’s long-term workforce plans.

4.11 NHS workforce productivity had been improving prior to the COVID-19 pandemic. Analysis published by the Centre for Health Economics in 2020 concluded that, from 2004-05 to 2017-18, NHS productivity increased by 18.0% and that since 2009-10 NHS productivity growth had improved significantly faster than the overall economy.6

4.12 Our November 2022 report, Managing NHS backlogs and waiting times in England, noted concern about reduced overall productivity by local and national NHS officials, with the same staff and infrastructure completing less work than before the pandemic.7 The NHS recognises that it continues to face productivity challenges, some a direct result of the pandemic, such as increased staff absences and infection control measures. Other factors NHSE identified include a reduced willingness by staff to offer discretionary overtime and an increase in delayed discharges.

4.13 In March 2023, updated analysis by the Centre for Health Economics found that between 2019-20 and 2020-21, covering the onset of the COVID-19 pandemic, the Centre calculated that NHS productivity decreased by 23.0%, a reduction not echoed by a similar decline in the wider UK economy.8 It attributed this to overall NHS output decreasing by 16.1%, when adjusted for quality, and NHS inputs growing by 9.0%, when measured using a combination of direct and indirect inputs.9 The evidence set out in this report shows that, despite increases in NHS staff numbers, access to unplanned and urgent care services is below target performance levels, underlining the complexity of the challenge faced by DHSC and NHSE in implementing recovery plans.

6 University of York, Centre for Health Economics, Productivity of the English National Health Service: 2017/18 Update, CHE Research Paper 171, February 2020.

7 Comptroller and Auditor General, Managing NHS backlogs and waiting times in England, Session 2022-23, HC 799, National Audit Office, November 2022.

8 University of York, Centre for Health Economics, Productivity of the English National Health Service: 2020/21 Update, CHE Research Paper 190, March 2023.

9 NHS productivity growth is measured by comparing the growth in outputs produced by the NHS to the growth in inputs used to produce them. NHS outputs include all the activities undertaken for NHS patients wherever they are treated in England. It also accounts for changes in the quality of care provided to those patients. NHS inputs include the number of doctors, nurses and support staff providing care, the equipment and clinical supplies used, and the facilities of hospitals and other premises where care is provided.

Appendix One

Our evidence base

1 Our independent conclusions on access to NHS services for unplanned or urgent care were reached by analysing evidence collected between September 2022 and May 2023.

2 The analytical framework underpinning our conclusions used mainly publicly available data to understand and describe each NHS service covered in the report, in terms of their scale and recent and longer-term trends in demand, capacity and performance. This was supplemented by discussions with officials and selected stakeholders, and relevant evidence we requested from NHS England (NHSE) where this information was not publicly available.

3 The report is a landscape review that is largely fact-based, descriptive, and data-driven, with minimal evaluative comment and no value for money conclusion.

Quantitative analysis

4 We analysed publicly available data at local, regional, and national levels to understand recent and longer-term trends in the services covered in the report. We collected and analysed data across three categories:

Demand

Appointments in general practice offered, appointment waiting times and appointment methods.

Ambulance control room and 111 calls, and 111 call outcomes.

Ambulance incidents.

Accident and emergency (A&E) attendances and admissions.

Capacity

NHS hospital beds, including total numbers, occupancy rates, beds occupied due to COVID-19, length of stay, and delayed discharges.

NHS workforce data, including: total NHS staff numbers; staffing trends for ambulance services, GPs and emergency department doctors; and NHS vacancies by sector.

Performance

A&E waiting times for decisions about care and admission to wards.

Ambulance incident response times and handover times.

999 and 111 call response times.

Urgent community response times.

GP Patient Survey and 111 satisfaction scores.

Financial analysis

5 We analysed financial data available publicly in the NHS national cost collection, and provided by NHSE, to estimate costs associated with providing the services included in the report. All financial data are presented in nominal (cash) terms, unless otherwise stated.

Interviews

6 We conducted interviews with key representatives from the Department of Health & Social Care (DHSC), NHSE and third-party stakeholders during scoping and fieldwork stages to inform our audit.

Interviews with NHSE and DHSC, including interviews with key officials responsible for primary care, community pharmacy, and urgent and emergency care, to understand the background context, current pressures and future plans for each service.

Interviews with wider stakeholders. We interviewed representatives from health stakeholder organisations during the planning phase to understand wider sector views. We met with the Royal College of Emergency Medicine, Royal College of General Practitioners, College of Paramedics, Academy of Medical Royal Colleges, Royal Pharmaceutical Society, NHS Confederation, NHS Providers, Pharmaceutical Services Negotiating Scheme, Association of Ambulance Chief Executives, Health Foundation, and The King’s Fund.

Document review

7 We reviewed around 100 published and unpublished documents, which included submissions from NHSE in response to our evidence request. These documents informed our understanding of the services covered by the report, including their background history and context, recent and longer-term trends, current operational pressures, and future NHSE plans where relevant.

8 We reviewed policy and strategy documents, internal planning documents, operational planning guidance and good practice guides, board papers and minutes, previous National Audit Office reports, publicly available articles, and think tank pieces and analyses.

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