Pathways into emergency care and what they reveal about inequality

Emergency departments play a central role within the National Health Service (NHS), serving as a primary point of access for patients with urgent and complex health needs. Persistent concerns about overcrowding, prolonged waiting times, and repeat attendances have intensified interest in understanding how emergency care is accessed and delivered, particularly in relation to socioeconomic inequality. While it is well established that people living in more deprived areas attend emergency departments more frequently and often experience poorer outcomes, less attention has been paid to the routes through which patients enter emergency care and the role these pathways play in shaping subsequent hospital experiences.

This blog draws directly on our recently published analysis in BMJ Open—“Socioeconomic deprivation and referral source in female and male emergency department attendances: a retrospective observational study” (BMJ Open 2025;15:e108770, https://bmjopen.bmj.com/content/15/12/e108770)—to explore how referral pathways into a large NHS teaching hospital’s emergency department vary by deprivation and how these pathways relate to key clinical and operational outcomes.

The NHS offers multiple routes into emergency departments, including referral by general practitioners, advice from NHS 111, arrival by emergency ambulance, and self-referral. These pathways differ not only in how patients physically enter hospital care, but also in the extent of clinical assessment, triage, and information transfer that occurs before arrival. From a health systems perspective, referral pathways can be understood as mechanisms that link patient need with service organisation, shaping both demand for emergency care and the efficiency with which it is delivered.

Clear socioeconomic patterns emerge when these pathways are examined in detail. Patients living in more deprived areas are substantially less likely to be referred to the emergency department by a GP or via NHS 111 and are more likely to arrive by ambulance or through unplanned routes. The contrast is particularly striking for GP referrals, which are more than three times as common among patients from the least deprived areas compared with those from the most deprived. These differences persist even after accounting for age, gender, clinical acuity, attendance reason, time of arrival, and broader system pressures, suggesting that they are not simply driven by differences in illness severity or timing of presentation.

These findings point towards structural inequalities in access to planned and supported routes into emergency care. Barriers to accessing general practice, lower uptake of telephone triage services, and differences in how individuals navigate the healthcare system may all contribute to these patterns. For patients in more deprived areas, emergency departments may function as a default point of access when other services are difficult to reach, rather than as a destination reached following structured clinical referral.

While socioeconomic differences in access pathways are pronounced, a key finding of this study is that once patients enter the emergency department, referral source plays a more important role than deprivation itself in shaping hospital outcomes. Across multiple measures, including total time spent in the department, likelihood of breaching the four-hour waiting time target, hospital admission, and unplanned return visits, outcomes vary far more by referral pathway than by socioeconomic status.

Patients referred via NHS 111 consistently experience shorter stays in the emergency department, lower probabilities of breaching the four-hour target, and fewer unplanned returns within a short period following discharge. GP referrals show similarly favourable patterns, particularly with respect to reattendance. In contrast, patients arriving by ambulance experience the longest stays and the highest likelihood of four-hour breaches across all deprivation groups. Self-referrals, while representing the largest single pathway into emergency care, are associated with the highest rates of unplanned return visits, indicating potential gaps in resolution or follow-up.

Importantly, within each referral category, differences between socioeconomic groups are relatively small and often clinically negligible. Patients from more deprived areas are not systematically disadvantaged once they arrive through the same pathway as those from less deprived areas. This suggests that inequalities in emergency care outcomes are not primarily driven by differential treatment within the department, but rather by unequal access to pathways that facilitate earlier assessment, clearer clinical information, and more coordinated entry into emergency services.

Referral pathways appear to capture important system-level factors that extend beyond individual clinical need. Structured referrals from GPs or NHS 111 often involve prior triage, documentation, and decision-making that can streamline care once patients arrive at the emergency department. By contrast, ambulance arrivals and self-presentations may reflect delayed care-seeking, crisis-driven access, or unmet needs elsewhere in the system. These differences influence how patients are processed within the department, affecting waiting times, admission decisions, and the likelihood of repeat attendance.

The findings support a two-stage understanding of inequality in emergency care. The first stage occurs before hospital arrival, where socioeconomic disadvantage is associated with reduced access to structured and planned referral routes. The second stage unfolds within the emergency department, where the referral pathway, rather than socioeconomic background, shapes patient flow and outcomes. This distinction is important, as it shifts the focus of intervention away from emergency departments alone and towards the broader urgent and primary care system.

The implications for policy and practice are significant. Ambulance services are among the most resource-intensive components of emergency care, and higher reliance on ambulance pathways among deprived populations carries both financial and operational consequences for the NHS. At the same time, the consistently better outcomes associated with GP and NHS 111 referrals suggest that strengthening these pathways could improve both efficiency and equity. Facilitating timely access to primary care, enhancing awareness and trust in telephone triage services, and reducing barriers to planned referral routes may help mitigate downstream pressures on emergency departments.

The prominence of self-referral across all socioeconomic groups also warrants attention. While self-presentation is an appropriate and necessary route for many patients, its association with higher rates of unplanned return suggests scope for improving discharge planning, safety-netting, and follow-up support. Interventions that enhance continuity of care after emergency department discharge may be particularly beneficial for patients who enter care without prior referral.

As with all observational studies, these findings should be interpreted with appropriate caution. The analysis cannot establish causal relationships, and unmeasured factors such as patient preferences, prior healthcare experiences, or local service availability may influence both referral pathways and outcomes. The study is based on data from a single large teaching hospital located in a relatively affluent region of England, which may limit generalisability to other settings. Nevertheless, the richness of the dataset, particularly the inclusion of detailed referral source information and granular measures of clinical acuity, provides insights that are not currently available in many national administrative datasets.

Overall, this research highlights the importance of looking beyond the emergency department itself when addressing inequalities in emergency care. While emergency departments remain critical points of access within the NHS, the pathways that lead patients to their doors play a decisive role in shaping experiences and outcomes. Addressing socioeconomic inequalities in emergency care therefore requires attention to the organisation, accessibility, and integration of services across the wider health system. By improving access to structured referral routes and supporting more equitable navigation of urgent care services, it may be possible to reduce pressure on emergency departments while delivering fairer and more effective care for all patients.