A report published by the UK’s independent public spending watchdog, the National Audit Office (NAO), has found that NHS patients are experiencing reduced access to urgent or emergency care. NAO is an independent Parliamentary body which holds the government to account for its spending, to improve healthcare and other services and ensure that the public are receiving value for money. NAO’s report, Access to Unplanned or Urgent Care, provides an overview of NHS services that people use for rapid access to emergency, urgent and unplanned health care, such as general practice (GP), community pharmacy, NHS 111, 999, ambulance services and A&E. The report concludes that many of these important NHS services, which patients depend upon for emergency or urgent healthcare, are failing to meet the performance standards that patients have a right to expect. Statistics from the NAO report about patients’ access to urgent care General practice or GP care In March 2023 there were 6,442 GP practices in England, providing patients with medical advice, treatment and referrals to more specialist NHS services. 336 million appointments took place in GP practice in 2022/23, compared with 285.3 million in 2018/19. In October 2022 alone, GP practices handled a record number of 32 million appointments. However, patient satisfaction rates for appointments offered (at 71.9%) were the lowest they had been in five years. Community pharmacists Community pharmacies are located on the high street, in supermarkets and other public places, offering people the opportunity to see a pharmacist without making an appointment at more convenient times, including at weekends. Pharmacists can advise on medicines and treat minor illnesses or signpost patients to other services for more serious conditions. Patients who contact NHS 111 or their GP may be referred to a community pharmacist. There were 11,522 community pharmacies in England in 2021/22. In 2022, community pharmacists carried out an estimated 65 million consultations. A record number of 159,000 referrals were made to the Community Pharmacist Consultation Service in the month of December 2022. An IPSOS survey in September 2022 found that community pharmacies were the organisations that people were most likely to go to for advice about medicines or minor conditions, and that community pharmacy advice was rated as good by 91% of survey respondents who had used the service. NHS 111 calls NHS 111 is a free online and telephone service designed to help people with urgent, non-life-threatening medical or health issues. Calls are assessed by trained call handlers who provide advice or recommend further action, such as seeing a doctor, nurse or pharmacist, booking a GP appointment, or referral to ambulance services and A&E. NAO found a shift in the balance of outcomes from 111 calls since 2010/11, with a smaller proportion of calls resulting in advice to attend primary (eg GP) or community care services, and an increasing proportion of callers now being advised to attend A&E. In 2022/23 there were 22.3 million calls to NHS 111, up from 12.9 million in 2014/15. In December 2022, a record 2.9 million calls were made to NHS 111. In 2021/22, 8.4 million calls to NHS 111 were answered within 60 seconds, compared with up to 13.3 million in previous years. Fewer patients expressed positive satisfaction with NHS 111 in 2021/22 than in previous years. 999 calls and ambulance services Requests for ambulance services are coordinated by ambulance control rooms and may include calls that have been transferred from other emergency health professionals and rescue services such as 999 or 111. Around three quarters of ambulance service calls are from 999. Ambulance control rooms took 13.2 million calls in 2022/23 compared with 11.7 million calls in 2018/19. There were a record 101,089 ‘Category 1’ (life-threatening emergency) callouts in December 2022. The average time taken to answer ambulance-related 999 calls in December 2022 was 88 seconds, an all-time high compared with 14 seconds in March 2018. NHSE data from March 2023 relating to ambulance response times showed that many patients experienced significant delays: 90% of Category 1 emergencies were responded to within 15 minutes 38 seconds, compared with a target of 15 minutes. 90% of Category 2 incidents were responded to within 1 hour, 26 minutes and 15 seconds against a target of 40 minutes. 90% of Category 3 incidents were responded to within 5 hours, 21 minutes and 12 seconds against a target of two hours. 90% of Category 4 incidents were responded to within 6 hours, 54 minutes and 22 seconds against a target of three hours. More than a quarter (25.9%) of ambulance handovers of patients to A&E took longer than 30 minutes in March 2023. NAO says that the NHS has never met its 30 minute maximum target for all ambulance handovers according to available data for handover times since November 2017. Accident and emergency departments (A&E) A&E departments treat serious injuries and life-threatening emergencies. Around 170 A&E departments in England are classed as Type 1. These consultant-led units have full resuscitation facilities and treat patients with the most severe conditions. Type 2 A&Es treat single specialist areas, such as eye care. Type 3 A&E’s or Urgent Treatment Centres are led by a GP or nurse and treat minor injuries and illnesses. Patients arrive at A&E by ambulance or by walking in. The severity and urgency of their condition is assessed by a process known as triage before a decision is made to admit them to hospital, transfer them to another service or discharge. There were 25.2 million A&E attendances in 2022/23 compared with 21.6 million in 2011/12. In December 2022 there were a record 2.3 million A&E attendances. NHS standards expect 95% of A&E patients to be admitted, transferred or discharged within four hours of arrival. NAO reported that this standard has not been achieved across all A&E departments since July 2015. In March 2023, only 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, a record 711,881 A&E patients waited over four hours from their arrival to be admitted, transferred or discharged. NHS standards say that no A&E patient must wait longer than 12 hours to be admitted to a ward after the decision has been made to admit them to hospital. December 2022 saw record numbers of A&E patients waiting longer than 12 hours to be admitted to a ward. NAO notes that NHS England does not publish data about wait times beyond 12 hours, so it is not clear how long patients waited beyond the 12-hour threshold. What does NAO’s report say about how the NHS is performing? NAO’s Access to Unplanned or Urgent Care report estimates that there were nearly half a billion patient interactions across NHS urgent and emergency services in 2021/2022 and demand for healthcare is increasing as the population gets older. 10.4 million people in England were aged 65 or older in 2021, an increase of 20.1% from ten years before. 8.5 million NHS hospital patients were over 65 in 2021/22. Older people are more likely to have disability or multiple, chronic and complex health conditions. Research studies estimate that 52.8% of all adults in England had more than one long-term health condition in 2019, compared with 30.8% in 2004. Hospital bed capacity was affected by the pandemic and has now risen, but only back to pre-pandemic levels. General and acute hospital bed occupancy reached record levels at 92.3% in the final quarter of 2022/23. Critical care patients are staying longer in hospitals and the average number of patients who remain in hospital despite no longer needing inpatient care increased by 12% over the last year. High levels of bed occupancy increase the risk of bed shortage crises and the number of hospital-acquired infections. NAO echoed the findings of other reports which highlight that emergency and hospital services depend on each other to work effectively. Delayed ambulance handovers can lead to delayed ambulance response times for other waiting patients but are affected by the rate at which A&E departments can admit to the ward or discharge their patients. Admission of A&E patients to the wards are delayed by hospitals’ inability to discharge medically fit patients from the wards. NAO noted that the NHS measures the performance of individual services but does not measure patient flows across its services or the effect that one service has upon another. The total number of NHS staff increased to an all-time high of 1,275,354 in February 2023. The number of doctors working in emergency medicine has doubled in the past 13 years. However, the average rate of staff leaving ambulance trusts has increased, and 42.9% of ambulance staff told the 2022 NHS staff survey that they often think about leaving their organisations. A survey by the Royal College of General Practitioners (RCGP) in 2022 also found that 39% of GP respondents were considering leaving the profession within five years. In 2020, the government committed to providing 6,000 more GPs, but has since stated that it is unlikely to achieve this goal. NAO notes that despite NHS England’s stated intention to publish its long-term workforce plan, there have already been repeated delays in publication of the promised plan. Meanwhile, spending on the NHS continues to increase. The total budget for NHS England in 2022-23 was £152.6 billion, with the cost of providing services for unplanned or urgent care estimated at £21.5 billion per year. NAO estimate that in 2020/21 the ambulance service accounted for £2.6 billion, emergency departments cost £4.6 billion, and general practice £12.6 billion. NAO concluded that the NHS has not secured the full benefits of its increased spending and additional staff. NHS productivity has fallen since the start of the pandemic and the NHS has failed to meet key operational standards for unplanned or urgent care. The result for patients is that access to services for unplanned or urgent care has worsened. 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