How many excess deaths are A&E delays causing?

Earlier this month the Royal College of Emergency Medicine (RCEM) made the headlines with a widely-reported estimate that between 300 and 500 excess deaths are occurring each week in the UK due to A&E delays.

The organisation, which oversees emergency medicine training and examinations, has been making similar estimates since September last year, when it suggested there could be “500 excess deaths a week”.

However, NHS England (NHSE) spokespeople have repeatedly stated that they “don’t recognise these numbers” and warned against “jumping to conclusions”. Chris Hopson, Chief Strategy Officer at NHSE, pointed to other potential causes in a BBC interview [starting at 18 min] such as “inclement weather and rising population numbers”. 

With the 300-500 figure facing renewed scrutiny this week as the RCEM and NHSE give evidence to the Health and Social Care Committee on pressures in emergency care, we’ve looked at where the estimate comes from and what other data’s available. 

Where is the RCEM figure from?

The RCEM’s estimate stems from a 2021 study published in the Emergency Medicine Journal (EMJ). It found spending 8-12 hours in A&E between arrival and admission to a ward increased the risk of death within 30 days by 16%—equivalent to one extra death for every 72 patients. The NHS Constitution pledges that A&E patients should be admitted, discharged or transferred within four hours. Risk of death started to increase after five hours and the rate worsened as with longer waiting times.

The RCEM tried to apply this finding to recent A&E waiting time data. However, data on the number of patients waiting 8-12 hours in A&E is not available for all UK nations. 

We do have monthly data on patient wait times from Scotland and Wales, including 4-8 and 8-12 hour waits as well as waits over 12 hours. From Northern Ireland we only have monthly data on patients waiting over 4 and over 12 hours. 

In England the NHS publishes official monthly data on the time between the decision to admit an A&E patient to a ward and them being admitted, but only releases data annually on the number of people spending more than 12 hours in A&E from arrival. 

The RCEM told us that to come up with its original estimate it looked at the monthly number of patients spending over 12 hours in A&E for all four nations to make the data comparable. For England it used a monthly estimate for England derived from the annual data for 2021/22. 

It then divided this UK-wide figure by 72 to estimate the number of deaths in a month, and then divided again to come up with weekly totals.

Rather than publishing the specific figures it calculated though, the RCEM then made an adjustment resulting in a range of 300-500 deaths a week. We don’t know the exact details of how it did this, but it told us it did so in order to reflect month-to-month variance, and to adjust for a number of other factors—including worsening A&E delays and the fact that patients waiting 8-12 hours, and those who wait over 12 hours but are not admitted, aren’t included in its analysis.

After it first published its estimate, the RCEM obtained more recent monthly data from the NHS in England via a Freedom of Information Request.

Re-running its calculations using this more up-to-date data puts the estimate of weekly deaths slightly above 500 a week—and that’s only looking at patients waiting more than 12 hours. When we attempted to reproduce the RCEM’s calculations using figures from last September we came up with a broadly similar estimate—an estimated 530 deaths a week for the UK as a whole associated with delays of A&E waits of more than 12 hours.

What counts as an ‘excess death’?

While the RCEM figure was widely reported as relating to “excess deaths”—and the RCEM itself used that term in its press release—its estimate is in fact for the total number of deaths attributable to delays.

The term “excess deaths” is usually defined by the Office for National Statistics (ONS) as the number of deaths above the average over the past five years, though currently it excludes the pandemic period from this and compares instead to 2015 to 2019. ONS data for the week ending 23 December 2022 showed 2,493 excess deaths from all causes registered in England and Wales - the highest since February 2021.

Others define “excess deaths” against a different baseline. For example the Institute and Faculty of Actuaries told Full Fact its latest excess death statistics compare current death rates to 2019 only.

Crucially though, in calculating its estimate the RCEM did not compare to any previous time period. It told Full Fact this is because it believes “while some patients have always faced long waits, the scale of patients now facing extremely long waits is a new phenomenon – and every death as a result is an extra or excess death because they could have been prevented... We can see in years prior the extremely long waits for admission weren’t happening and so the deaths weren’t occurring.” 

Why might the estimate not be accurate?

There are various reasons why the RCEM’s figures may underestimate the number of additional deaths. 

As noted above, the EMJ paper didn’t calculate additional risk for patients waiting over 12 hours, due to doubts about the data and the small number of patients. 

But given the study showed longer delays increased the risk of death, it is plausible the risk would be even higher among people waiting over 12 hours than those waiting 8-12 hours, meaning the RCEM’s estimate could be too low.

Additionally, while the RCEM adjusted its estimate to account for patients waiting 8-12 hours as well as those waiting more than 12 hours, the recent FOI data from NHSE would suggest if anything this adjustment may not have gone far enough.

The RCEM’s original estimate was also calculated using data from 2021/22 for England, and even the FOI data currently only goes up to October for England. It's likely the number of people waiting more than 12 hours between arrival and admission has increased since, given we know the number waiting more than 12 hours between the decision to admit and admission has increased significantly in recent months.  

Finally, the estimate does not take into account knock on effects of A&E waits. Long waits in A&E can also cause delays outside the hospital due to ambulance handover times increasing, and this could also cause additional deaths.

On the other hand, it’s also possible the RCEM figures may be an overestimate in some respects.

We can’t be sure that applying the EMJ study’s findings to current patients is entirely valid. For example, if patients are prioritised differently due to increased delays, the risk to patients waiting over 12 hours now may be higher or lower than to those in the study who waited that long when it was conducted in 2016-2018.

Even if that’s not the case, there’s still a degree of uncertainty about the underlying ‘one-in-72’ estimate from the EMJ study, and whether the deaths observed after delays in care were caused by those delays.

Also the EMJ study was based on the increased risk of death due to delays in type 1 (major) A&E departments. While most A&E attendances are in type 1 departments, and the vast majority of long delays are in these departments, Scottish, Welsh and English waiting time data is not separated by A&E type, so the one-in-72 figure may not be relevant to all the delays identified.   

The one-in-72 figure was estimated based on patients admitted to a ward, though the waiting time data includes all people who attended A&E, including those who may have been discharged and not admitted (though on this the RCEM says it’s been told by clinicians that it’s “extremely likely” any patient waiting more than 12 hours will be admitted).   

Finally, as outlined above the RCEM estimated the number of additional deaths caused by delays. 

While A&E waiting times have increased sharply, there have consistently been some patients who’ve waited more than 12 hours in recent years—so it’s likely the estimate would have been lower if the RCEM had attempted to calculate “excess” deaths by comparing to previous years, as some other organisations have done. 

What does the NHS say?

A number of different spokespeople for the NHS have said they do not recognise the RCEM’s figures.

When asked on the BBC if he accepted that A&E delays have caused deaths, Professor Stephen Powis, National Medical Director of NHSE, said “it’s not unusual to see high levels of excess deaths in the winter”. 

When pushed to give an NHSE estimate of deaths due to delays in A&E he said it is “very difficult to say'” but that it was “not for us at [NHSE] to produce those figures, [it’s] for the ONS and others to look into”. 

However an ONS spokesperson told us: “We are not able to produce any analysis on deaths that are due to A&E delays. Our statistics are based on death registrations, so we analyse deaths (excess deaths in this case) based on information collected on the cause of death from the death registration.”

NHSE’s Chief Strategy Officer Chris Hopson also previously told the Today programme “a full and detailed look at the evidence…is now under way”, but we don’t have any further details of that work, or even know who is doing it.

Full Fact asked NHSE for details and whether there was a timeframe for this work being conducted and published, but NHSE did not reference this in their response to us. Mr Hopson is among those due to give evidence to the Health and Social Care Committee this week. 

An NHS spokesperson told us: ”High levels of excess deaths during winter are not unusual and as SAGE has repeatedly said are even likelier following the pandemic. 

“These can be down to a complex series of factors which makes identifying a definitive cause very difficult so it is right that the experts at the ONS—as the executive branch of the stats authority—continue to analyse excess deaths.”

What have other estimates found?

Other experts have attempted to make similar estimates.

The actuary firm LCP Health Analytics also used the EMJ paper along with NHS waiting time data to come up with an estimate, though it looked a slightly different set of metrics. Its published analysis estimated there were over 400 deaths a week between September and November due to A&E delays.

Unlike the RCEM, LCP Health Analytics also compared its estimate for the number of additional deaths to previous pre-pandemic years, and estimated an “excess deaths” figure of between 200 and 340 a week depending on the year compared to. Stuart McDonald, a partner at the firm, told us it was possible this was an underestimate, due to some of the same limitations we’ve noted in relation to the RCEM estimate above.

A similar calculation with broadly similar findings was also published by the Financial Times in September.

Professor Sir David Spiegelhalter, an expert in understanding risk and emeritus professor at Cambridge University, told Full Fact he found the RCEM’s claims “quite plausible” and that “the [EMJ] paper [...] seems particularly relevant as it is recent and NHS data.”

He added: ”Of course this is an observational study, and so not necessarily causal, but they have adjusted for important factors.”

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