A WISE DOCTOR once said that accident and emergency (A&E) departments were the “shop window” of the National Health Service (NHS). It was the experience of A&E, argued Sir George Alberti, who advised the previous Labour government in the 2000s, that shaped people’s views of the service. The current view through the glass is a dark one. In December 2024 only 55% of patients attending a major A&E in England were seen within four hours—an eon away from the 95% target routinely met in Sir George’s time. A survey last year by the Royal College of Nursing, a union, found that two-thirds of their members had treated patients in inappropriate settings, including corridors, waiting rooms and even car parks.
As standards have tumbled, 12-hour waits have become common (see chart), with dangerous consequences. In January the Office for National Statistics found that those waiting in A&E for more than 12 hours were twice as likely to die within 30 days as those who waited only two hours, even when controlling for other factors such as self-reported health. These figures support findings by the Royal College of Emergency Medicine (RCEM), which estimated in 2023 that long waits in A&E were likely to be responsible for around 14,000 extra deaths a year.
The causes of this crisis are many. One factor highlighted by Lord Ara Darzi, another doctor-cum-adviser, in his recent review of the NHS, is the sustained underfunding of primary and community care. Relative to its population Britain has 16% fewer fully qualified GPs than other rich countries. That pushes people towards A&E. So too does a lack of mental-health care in the community: those suffering from mental illness are twice as likely as other people to wait for more than 12 hours in emergency departments.
Increasing demand alone cannot account for the chaos. In 2024 the number of patients attending A&E rose by 7%, but the number who waited for over 12 hours rose by 25%. That suggests that patients are not moving through the hospital quickly enough. One in eight beds could be freed up if patients were moved on to places of more appropriate care more efficiently. Shoddy discharge planning, poor co-ordination and a lack of capacity in social care prevents that from happening. A shortage of hospital beds has also made it harder to absorb pressure in the wake of the covid-19 pandemic. High occupancy rates, once only a feature of winters, are now normal.
The NHS has ideas for how to relieve some of the pressure on A&E waiting rooms, as a recently leaked plan revealed. Ministers hope that more emergency callers can be given advice on the phone, rather than a visit by paramedics; “rapid triage” at the front door of hospitals could also help to divert admissions where possible. These are good ideas, even if they have been suggested many times before. But fixing A&E will ultimately depend on tackling far more ingrained problems.
The government’s judgment is that it is best to focus attention and resources on cutting hospital waiting lists for non-emergency procedures. “Deciding to focus on the elective-care target tacitly deprioritises everything else,” says Professor Adrian Boyle, the head of the RCEM. That may reflect the public’s top concerns, given that one in nine people in England are waiting for routine hospital treatment. But without serious change, that NHS shop window will continue to look rather grim. ■
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