Four Hour A&E Waiting Targets Being Revised

Nicky Broyd

March 11, 2019

The promise of a waiting time no longer than 4 hours in accident and emergency (A&E) departments in England may be replaced with a series of new targets as low as 1 hour for some serious conditions.

NHS England has set out proposals for what it calls "clinical improvements that aim to deliver rapid assessment and treatment". Mental health will be given equal priority alongside physical conditions.

The pressures on A&E departments in the winter have meant the 4-hour target is often breached. The Royal College of Emergency Medicine's latest analysis showed the average 4-hour performance at more than 50 emergency departments was 79.01%. That was an improvement on 76.87% the week before, ending 17th February.

New Standards

NHS England says its statistics show that around a fifth of emergency admissions from A&E take place in the 10 minutes at the end of the current 4-hour target. It calls this a 'cliff edge' target, suggesting there's a focus on deadlines rather than individual patient needs.

Under the new proposals the time taken initially to assess patients when they present to A&E will be measured. Targets will then focus on treating the most urgent cases by clinical priority.

There's a new focus on conditions including mental health, sepsis, heart attack, and stroke.

If trials of new systems are deemed a success the new scheme could be in place by April 2020.

Professor Stephen Powis, NHS England’s national medical director and review lead, said: " …now is the right time to look again at the old targets which have such a big influence on how care is delivered, to make sure that they take account of the latest treatments and techniques, and support, not hinder, staff to deliver the kind of responsive, high-quality services that people want to see."

Professor Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: "The 4-hour A&E standard has been valuable in focussing efforts on improving emergency care but if we are to continue to improve patient safety and ensure every patient gets the priority they individually need it must be reformed, and we must find better measures to ensure patient safety.

"Emergency departments need a set of standards which gives priority to patients with life-threatening conditions, ensures people get care in a timely way and puts pressure on the whole hospital to end long corridor waits for those who need admitting. We are confident that field testing these proposals is the safest and most effective way of improving care."


Several groups have issued statements reacting to the proposals.

Richard Murray, chief executive of The King’s Fund, said: "NHS waiting times standards are powerful tools that have played a key role in improving the experience of patients. But these targets have also resulted in some unintended consequences and many of them were developed well over a decade ago – so it is right to consider whether they are still fit for purpose."

He continued: "It is right to pilot the proposed changes to accident and emergency and planned hospital treatment to understand their impact on patient safety and the quality of care. However, these targets have not been met for several years and continue to be missed by a wide margin so it is important to be realistic. Changing existing targets and introducing new standards is not a panacea for improving patient care - without enough staff and resources to care for patients, targets both new and old will continue to be missed."

The Royal College of Emergency Medicine (RCEM) said it supported the continued use of the 4-hour metrics.

RCEM President Dr Taj Hassan said: " …we are keen to ensure that any changes are not imposed due to political will but are developed responsibly, collaboratively and are based upon clinical expert consensus in the best interests of patients."

It has issued its own position statement on targets. Dr Hassan said: "The measures set out in this document are what we believe are in the best interests of patients and will enhance and refine the 4-hour standard as a powerful system measure of flow. These have been developed based on the expert opinion of clinicians working in emergency medicine and are supported by a range of colleagues from other specialties. We also note that the last multidisciplinary evidence-based review in Scotland by Sir Harry Burns in November 2017 clearly stated that the 4-hour standard should be retained."

Dr Nick Scriven, president of the Society for Acute Medicine (SAM), said: "Back in 2016, SAM made loud and clear calls for the NHS to stop aiming only to meet the 4-hour standard when it was clear a whole system approach was required.

"The review of the target is an opportunity to focus on a range of patient outcomes and quality standards to measure pressures and take effective action earlier."

Professor Carrie MacEwan, president of the Academy of Medical Royal Colleges, said: "We support any moves that improve the quality of care. If, as seems likely, the new standards on cancer, mental health, waiting times for both elective (referral to treatment times RTT) and in emergency care are demonstrably in the best interests of patients then we will support those. We look forward to working with NHS England and other stakeholders on a full evaluation of the pilot studies and any subsequent changes that are decided upon as a result."

Paul Farmer, chief executive of mental health charity Mind, said: "This target, along with better care in the community, could help people avoid reaching crisis and offer them quick support when they do. Treating people in their own homes or providing sanctuaries, safe havens and crisis cafes should mean more people are able to receive help without needing to go to a clinical setting."


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