6 Mar 2015

Our third policy briefing in the run up to the General Election 2015 examines the real reasons behind England’s  A&E ‘crisis’, and warns that the emphasis on the four-hour waiting time target has become disproportionate. It also makes some recommendations to policy makers on how performance management should be approached in the future.


In the run-up to the General Election, we are producing a series of policy briefings on the issues and challenges that are critical to the longer term success of the health and social care system - the issues any Government after 2015 will need to prioritise. 

England's A&E system is near crisis. With the financial squeeze set to continue, there is no relief in sight if we keep up the current approach. We need to rethink our assumptions as many of the ‘magic bullet’ solutions suggested miss the point. It's not about more people turning up, but about a system with a squeeze on hospital space and staff, which needs to get better at discharging people safely and on time.

Nigel Edwards, Chief Executive and briefing co-author

What’s behind the A&E ‘crisis’? by Nigel Edwards, Ian Blunt and Leonora Merry, explores the way that performance is measured in A&E and argues that new approaches to performance management, with other measures given equal status to the four-hour target, should be adopted. 

In the briefing, we note that while measuring performance of A&E departments is essential, the four-hour target can distort behaviours inside hospitals in ways that are not in the interests of patients or staff. This can mean significant amount of staff time is spent reporting upwards to commissioners and regulators, with potentially detrimental impacts on the quality of care.

Instead, the briefing recommends policy makers should take a longer term and broader view of performance in A&E, which may involve relegating the four-hour target to sit alongside a richer set of indicators. 

We also argue that the cause of A&E pressures has been misunderstood, and long-term trends and immediate causes conflated, with too much focus on the 2004 GP contract, NHS 111 and the gradual increase in admissions, rather than broader issues of hospital discharge and patient flow.

The briefing presents the latest data on A&E, showing that major A&Es have not met the four-hour target since 2013; the number of patients waiting on trolleys for over four hours has almost trebled since 2010/11; and the numbers of delayed ambulance handovers have risen by 70 per cent over the same period. At the same time waiting times to treatment at A&E and re-attendances within seven days have changed little.

Email to a friend

Your message will be:

I thought you might be interested in this page on The Nuffield Trust website.