Emergency departments performed better during many of the strikes that took place between 2022 and 2024. At first glance, this might seem odd. Despite the disruption, patients received emergency care more promptly. So, what changed, and what can we learn from it?
Between December 2022 and July 2024, doctors, nurses, and many other staff groups took industrial action in protest over NHS pay and conditions. Strikes in the NHS are not unusual, but the scale and duration of these strikes was exceptional. Operations, diagnostic tests, and outpatient consultations were cancelled or postponed, and this meant that waiting lists for planned care grew.
The impact on emergency pathways is less clear-cut. Perhaps counter-intuitively, in 2023, the president of the Royal College of Emergency Medicine said that the effect of the strikes on emergency departments (ED) was that:
“…everything works better than usual.”
This view is supported by studies from London and the North-West of England, which showed that waiting times in EDs had indeed reduced on some of the days when industrial action took place.
Perhaps this should not come as a total surprise. The NHS and its staff go to enormous lengths to ensure that patients requiring urgent help do not suffer adverse consequences when strikes are taking place. Extra efforts are taken to reduce bed occupancy, staff are brought in to provide cover, non-urgent services are scaled back, and services outside of hospital step-up to divert demand. Patients also play their part by staying away from ED when they can.
Such changes provide a valuable opportunity to learn. Knowing which adaptations made a difference would help us mitigating negative impacts during future strikes; and could even inform our efforts to improve ED operations in normal times. These changes occurred simultaneously and were almost ubiquitous, so identifying which ones really improved patient flow is challenging. This was hardly a controlled experiment.
The Strategy Unit explored this issue last year, supported by colleagues from The University of Liverpool and the Health Foundation. The work was published in the Journal of the Royal Society of Medicine earlier this month. We analysed 3.6 million ED attendances at 20 hospital trusts using a novel method known as causal mediation analysis.
Readers wanting detail should consult the paper, but here are the headlines:
Patient flow through ED improved during most strikes
Patient care was handled more promptly during most strikes. The effect was strongest during the resident doctor strikes, where patient durations reduced by 13%. The same effect was present, but less marked, during the consultant and paramedic strikes; but we found no effect during nurse strikes.
For a few days in 2023, both resident doctors and consultants took industrial action. On these occasions, patients spent longer in ED. This suggests that mitigating the impact of strikes is more challenging when they are coordinated.
Pre-strike efforts to discharge patients were critical
On the eve of strikes, many trusts redoubled their efforts to discharge medically-fit patients from hospital beds. This strategy was successful, leading to a reduction in the time patients spent in ED during strikes. This fits with existing studies showing that high inpatient bed occupancy slows patient flow through ED.
Scaling back planned care had no impact on ED flow
Outpatient care and planned procedures were scaled back significantly during the strikes. This may have been because staff who would have delivered this care withdrew their labour. But scaling back planned care is also thought to free up staff and capacity that can be made available to manage emergency patients.
And yet we found that these substantial reductions in planned care had no impact on flow through ED. The trade-off between elective and emergency performance is an issue we hope to explore further through our partnership with the Health Foundation.
Changes in clinical practice eased flow
The strikes led to changes in the skill mix of staff. During the resident doctor strikes, consultants, senior nurses and senior AHPs provided cover, for example. Having controlled for patient casemix, we found no change in the rate of diagnostic imaging - but more treatments were delivered, and patients were less likely to be admitted. The combined effect led to shorter durations in ED.
ED demand reduced, but this had minimal impact on flow
Paramedics and nurses were the first to take industrial action. During these strikes, the number of people attending ED reduced by 2-5%, and GP appointments increased at a similar rate. ED flow improved as a consequence - but the impact was marginal. Diverting patients will ease pressure, but it will not solve the NHS’ 4-hour performance problems.
Crucial pieces of the puzzle remain missing
Taken together these factors can explain some, but not all of the improvement in ED flow that was observed during the strikes. So, what else made the difference?
The most direct and obvious impact of the strikes was to change the number and types of personnel working in EDs. Unfortunately, these changes can only be inferred, since there is no statutory reporting of ED rotas - and the special collections that were introduced during strikes do not provide this information.
More generally, the evidence base on the relationship between staffing levels, skill mix, and ED flow is strangely limited. This is remarkable, given the public, clinical and political concern about waiting times in ED. New data sources mean that this gap can now be addressed. This is a topic we hope to explore in the future.
Strikes have many impacts, and their consequences can ripple out in unexpected ways. It will be interesting to see whether knowledge generated by these strikes improves ED practice in ‘normal times’.
Read the full journal article here: https://doi.org/10.1177/01410768261461989