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Welcome to the Editor’s Choice in this spring issue of EMJ. In the past, the arrival of spring heralded a reprieve in winter pressures and crowding in our emergency departments (EDs). However, this is no longer the case; crowding and pressures continue unabated, with many departments experiencing what has been described by RCEM as a ‘perpetual winter’. Rising demand and limited access to primary care are frequently trotted out as the reasons for the unrelenting pressures on our EDs, but this isn’t the whole story, and indeed it’s an oversimplification. A study by Alkhatib et al from Imperial College London suggests an equally critical yet often overlooked factor is the increasing complexity of cases. This study assessed ED attendance trends for the Northwest London population between February 2017 and September 2023, before, during and after the pandemic lockdown measures (March 2020–March 2021) in the UK as a whole and across sociodemographic and multimorbidity profiles. They found that before the pandemic, there was a statistically significant annual growth rate of 3.4% and a rising trend in attendances was observed in all patient groups. After the pandemic, the overall trend stabilised; however, attendances have continued to rise for older age groups (61–75 and 76+), amplified for patients with multimorbidity and complex multimorbidity, while attendances declined for the least deprived. For the other patient groups, attendance plateaued. These findings will come as no surprise to ED clinicians who have been highlighting this as their day-to-day experience for some time, citing this complexity as a real concern for patient safety, quality care and efficient flow through the ED. We can only hope that having this robust data now to support these viewpoints previously and continuously expressed may prompt the action that is needed from our policy makers. Do also read the accompanying eloquent commentary on this paper by Sarah Scobie.