Unequal Paths to the Emergency Department: How Socioeconomic Deprivation Shapes Access to Urgent Care in England

Emergency departments (ED) in England are often viewed as the point in the healthcare system where everyone, regardless of background, receives urgent care on equal terms. Once a patient arrives, clinicians prioritise treatment based on illness severity rather than social or demographic characteristics. However, the journey that brings a person to the emergency department is not the same for everyone. New research using more than 480,000 adult attendances shows that the way patients reach the ED varies markedly by socioeconomic deprivation, and these access routes have an important influence on what happens once patients enter the department.

The study, conducted at Cambridge University Hospitals between 2019 and 2023, focuses on what it calls ‘referral pathways’. These are the channels through which patients enter the emergency care system, such as GP referral, NHS 111 recommendation, ambulance, or self-referral by walking in. Although these pathways are often taken for granted, they capture essential differences in access to earlier stages of care, the timeliness of help-seeking, and the level of triage a patient has already undergone. They also reflect broader structural inequalities that shape how different groups interact with the NHS.

Understanding these pathways is crucial because the analysis shows that once inside the ED, the strongest predictor of outcomes is not deprivation itself but the referral route. This means that inequalities in emergency care begin well before the patient reaches the hospital door.

A System Shaped by Multiple Access Routes

The NHS operates through a gatekeeping model that encourages people to seek help first through their GP or, outside of practice hours, through NHS 111. These services are designed to ensure that patients receive the right type of care and that emergency departments remain focused on urgent and life-threatening conditions. However, this system only works if people can access these early forms of advice and assessment. For many, especially those living in deprived areas, this access is uneven.

Figure 1. Referral Source Distribution by IMD Deciles

Referral routes differ greatly across deprivation levels. GP and NHS 111 referrals are much less common among the most deprived patients, while ambulance use is significantly higher.

How Patients Reach the ED

Self-referral is the most common pathway across all socioeconomic groups, but beyond that headline pattern, the social gradient becomes clear. GP referrals show one of the most pronounced differences. Only around 4.7 percent of patients from the most deprived areas arrive following a GP referral, compared with nearly 15 percent in the least deprived areas. This gap cannot be explained by differences in illness severity alone. Instead, it reflects longstanding challenges in primary care access, including difficulties securing appointments, shorter consultations, less continuity of care, and lower levels of trust or engagement among groups facing socioeconomic disadvantage.

NHS 111 referrals follow a similar pattern. Patients in deprived areas are consistently less likely to use or benefit from NHS 111 triage. This may relate to limited digital access, uncertainty about how to use the service, or reservations about receiving remote clinical advice. Yet NHS 111 was designed to reduce avoidable ED attendances and to guide people to the right service. When engagement with it differs by socioeconomic position, the system begins to reproduce inequality.

Ambulance use tells a different but equally revealing story. Patients in more deprived areas rely more heavily on ambulances to reach the ED. Although part of this reflects differences in presenting conditions, the analysis shows that ambulance use remains higher among deprived populations even after controlling for clinical factors. This suggests that the ambulance service often becomes a default point of access where primary care is hard to reach or where people delay seeking help until a condition has significantly worsened.

The study also identifies higher levels of referrals from other medical sources and from police or forensic services among deprived groups. These include referrals from urgent treatment centres, mental health teams, community practitioners, or crisis responders. Such patterns point to complex social needs and greater exposure to crisis-driven situations that cut across health and social care systems.

Different Clinical Presentations and Their Consequences

The type of condition that brings someone to the ED varies across socioeconomic groups, and this influences the likelihood of arriving by ambulance, police referral, or self-referral.

Figure 2. Attendance Reasons for IMD10 (Least Deprived) and IMD1 (Most Deprived)

Patients from deprived areas present more often with trauma, injuries, and acute mental health issues, which contribute to different access routes into the ED.

Patients in deprived areas are more likely to attend with injuries, trauma, and acute mental health crises. These conditions often require urgent or emergency responses and may involve ambulance services or crisis support. By contrast, patients from less deprived areas more often present with conditions that can be triaged earlier through primary care. Despite these differences, however, the social gradient in referral patterns persists even after adjusting for attendance reason and clinical acuity. This suggests that the disparity is not simply a reflection of different health needs but also of differential access to early intervention and structured care pathways.

Patterns in ED Outcomes Across Referral Pathways

One of the most important findings of the study is that the referral route strongly determines what happens once the patient enters the ED. In fact, referral source is more predictive of outcomes than deprivation itself.

Patients referred by GPs or other medical professionals have the highest likelihood of hospital admission. This is expected because these routes involve a prior assessment that identifies patients likely to require inpatient care. Ambulance arrivals also show relatively high admission rates and experience some of the longest stays in the department. These patients often require extensive investigation or stabilisation, and waiting for an inpatient bed can prolong their length of stay.

In contrast, NHS 111 referrals are associated with significantly shorter stays and lower admission rates. The 111-triage process appears to identify many patients who need urgent assessment but not prolonged treatment or admission. The study suggests that NHS 111 creates a smoother patient journey by preparing the ED for what to expect and ensuring that those who arrive are generally appropriate for same-day assessment.

Self-referrals fall between these extremes. Although they often result in discharge rather than admission, they are associated with the highest rates of unplanned return within 72 hours, especially among deprived groups. This pattern implies that some self-presenting patients leave the ED with unresolved issues or without the necessary support to manage their condition at home. It may also reflect a lack of reliable access to follow-up care, making the ED the most accessible point of return.

Inequalities That Begin Long Before the Hospital Door

The overall picture that emerges is one in which inequalities in emergency care are shaped upstream rather than inside the ED. Once patients arrive, clinicians treat based on need, and the differences in outcomes across deprivation levels are relatively modest. The referral pathways, however, differ profoundly and contribute to unequal experiences of emergency care.

These pathways are closely linked to broader issues in the health system. In deprived areas, primary care access is often strained, leaving patients without timely alternatives to the ED. NHS 111, despite its potential to improve navigation of urgent care, is underused in these communities. As a result, deprived groups rely more heavily on ambulances and crisis responses, pathways that are more disruptive, more expensive, and more likely to result in longer ED stays.

The policy implications are significant. Strengthening access to GP appointments, improving continuity of care, and enhancing the usability and trustworthiness of NHS 111 could all help redirect patients toward more efficient and supported pathways. Reducing unnecessary reliance on ambulances not only improves equity but also benefits NHS resources, given the high cost of ambulance journeys compared with telephone triage or primary care assessment.

Conclusion

Emergency departments remain a critical safety net for the population, but they are not the starting point of most patients’ journeys. The study shows that inequalities in emergency care arise largely from the ways people reach the ED, long before clinical treatment begins. Addressing these access routes is therefore essential for building a fairer and more effective urgent care system.