The four-hour A&E waiting time target is a pledge set out in the Handbook to the NHS Constitution. The operational standard set in 2010 stated that at least 95% of patients attending A&E should be admitted, transferred or discharged within four hours. In December 2022, an intermediary threshold target of 76% to be hit by March 2024 was introduced with further improvement expected in 2024/25.
In March 2019, the Review of NHS Access Standards was published, which proposed that the current four-hour A&E target should be replaced by a set of access standards, including the average waiting time in A&E, time to initial clinical assessment, and time to emergency treatment for critically ill and injured patients. NHS England selected 14 hospital trusts to field test the new standards, and an interim report was published in October 2019. NHS England consulted on the proposed new standards, and the response to the consultation stated that the new standards will be rolled out. However, in September 2022 the then Health Secretary, Thérèse Coffey, ruled out changes to the four-hour target soon after her appointment, which means that the existing four-hour target remains in force for the foreseeable future. Read the Nuffield Trust blog for more information about the previously proposed A&E targets.
This indicator explores breaches of the four-hour A&E target since 2010. For in-depth analysis of what's causing increasing A&E waits, see our report Focus on: A&E attendances. See also our NHS performance summaries, which present up-to-date information on key NHS performance measures as data are released by NHS England.
A&E waiting times and attendances
The length of time patients spend in A&E before admission, transfer or discharge depends on the type of A&E unit they visit. In the past, minor A&Es (types 2 and 3, such as single specialty departments or minor injury units) nearly always admitted, transferred or discharged patients in less than four hours, whereas major A&Es (type 1) dealt with a higher number of attendees and more serious cases, and consistently performed worse at the four-hour target.
The target for the percentage of patients arriving at A&E that are admitted, transferred or discharged within four hours was relaxed from 98% to 95% in 2010. Performance for type 1 A&E departments between 2011/12 and 2013/14 remained close to or above the new target but has declined substantially since then. By Q3 2019/20 (October to December 2019), performance had fallen to a pre-pandemic low of 71%. The total number of A&E attendances had been increasing over time, reaching almost 6.5 million in Q3 2019/20.
In Q1 2020/21, the total number of A&E attendances fell dramatically to 3.6 million, following the outbreak of the coronavirus (Covid-19) pandemic, and waiting time performance for type 1 attendances temporarily improved sharply to 90%. This may reflect guidance to call NHS 111 with concerns about Covid-19 symptoms, as well as messaging encouraging people to stay at home during the national lockdown.
The number of A&E attendances has now returned to pre-pandemic levels but performance against the four-hour target has worsened. In Q4 2022/23 there were around 6 million A&E attendances. Waiting time performance worsened for all types of A&E attendances: 57% of patients attending type 1 departments were admitted, transferred, or discharged within four hours, and for patients attending type 2&3 departments the proportion was 96%.
In summer 2020, pilots began for a ‘call first’ model of urgent care, where patients with an urgent medical need were asked to call NHS 111, and those recommended to attend A&E were given a booked time slot to attend. Between Q4 2020/21 and Q4 2022/23, the total number of booked attendances at A&E increased from 92,363 to 209,709 (data not shown). In Q4 2022/23, this represented only 3% of total A&E attendances.
A&E wait times by month
The impact of winter pressures on performance against the four-hour A&E target is apparent. There is a general trend for performance to be higher in the summer months. This may be explained by changes in the case-mix of people attending. In summer, A&E departments see a higher proportion of cuts and sprains, most of which can be treated relatively quickly. In winter, there is a larger proportion of older people attending and a greater number of people requiring emergency admission to hospital.
Overall, there has been a year-on-year decrease in the proportion of patients attending major A&E departments that are admitted, transferred, or discharged within four hours.
In previous years, drops in performance have normally been observed from November onwards, and performance generally recovers at least partially by April the following year. However, this was less observable in 2021/22, as performance continued to worsen throughout the year. In 2022/23, performance continued to worsen throughout the year, particularly in December 2022 when it fell to 50%. It has since recovered slightly, to 57% as of March 2023.
Time spent by patients in A&E
As well as looking at the proportion of patients attending A&E who are admitted, transferred or discharged within four hours, we can also examine the median number of minutes spent in A&E. The median waiting time for all patients increased from 2 hours 9 minutes in May 2011 to 2 hours 54 minutes in December 2019, before falling to 2 hours 15 minutes in May 2020 during the Covid-19 outbreak. Since then, the median waiting time for all patients has increased to 3 hours 2 minutes in March 2023.
For patients who required admission to hospital, the median A&E waiting time remained below four hours until September 2019. In December 2019, the median wait increased to a high of 5 hours 21 minutes. This may reflect the increase in trolley waits (the time patients wait to be admitted onto a ward after the decision to admit has been made) in the winter of 2019/20. Following the onset of the Covid-19 pandemic, the median wait time dropped to 3 hours 59 minutes in March 2020 and remained relatively consistent up until June 2021, barring a small spike in January 2021 where it climbed to 4 hours 25 minutes. Following June 2021, the median waiting time for admitted patients increased steadily until it reached a new high of 7 hours 39 minutes in December 2022, as trolley waits soared after an increasingly intense period for this measure. Since then, the median waiting time has come down to 5 hours 59 minutes in March 2023.
In March 2023, the median waiting time for non-admitted patients (which has seen a steadier and less dramatic overall increase) was 2 hours 42 minutes, less than half the time for admitted patients.
It is worth noting that this data, provided by NHS England, is provisional and has data quality issues (see ‘About this data’ for more information).
A&E wait times from arrival till treatment
While adherence to the four-hour target is the long-standing measure of A&E performance, the length of time between patients arriving in A&E and their treatment beginning is another important indicator. The median treatment waiting time remained steady until February 2020, then became more variable, ranging from a low of 24 minutes in April 2020 to 1 hour 9 minutes in March 2023.
Interestingly, the 95th percentile value – that is, waiting times for some of the patients that wait the longest – fluctuated at around 3 hours 5 minutes until August 2015, before increasing to a pre-pandemic high of 4 hours 37 minutes in December 2019. In April 2020, the 95th percentile value fell dramatically to 2 hours 1 minute, before increasing to 5 hours 24 minutes in March 2023, in a series of sharp rises and smaller dips. It’s worth noting that this measure can be sensitive to data quality issues.
For patients that require admission to a hospital ward, either from A&E or via other routes, the time they wait between the A&E unit deciding that they should be admitted and the patient actually arriving on the ward is very important.
Trolley waits – the number of patients waiting over four hours between the decision to admit and admission – tend to be highest in the winter months and have increased over time. However, trolley waits continued to increase over the summer of 2022, higher than the winter of 2021-22, and rose even further into the winter of 2022-23. In December 2022, one in three patients (170,283) were waiting over four hours from decision to admission. Although the ratio improved to one in five patients in April 2023, it still meant that over 100,000 patients waited over four hours from decision to admission.
The bars on the chart show the number of people waiting over 12 hours to be admitted to a ward after a decision is made to admit them. The number of extreme waits peaked in December 2022 at 54,532 – more than four times higher than in December 2021, dwarfing pre-pandemic numbers which were typically only in the tens or hundreds. Since then, numbers have slid back down to half of what they were in December 2022 to reach 26,899 in April 2023, representing 6% of the total number of emergency admissions.
The Royal College of Emergency Medicine estimates that for every 72 patients waiting 8–12 hours from their time of arrival at an emergency department, there is one patient death. In recently published data for April 2023, it was estimated that 8% of patients attending A&E waited over 12 hours from their time of arrival (data not shown). In the planning and operational guidance published by NHS England for 2022/23, 12-hour waits (from the time of arrival) were meant to not exceed 2% and gradually subside to zero.
About this data
NHS England data
In March 2019, the Clinically-Led Review of NHS Access Standards Interim Report was released, proposing some significant changes to A&E waiting time targets. A six-month Progress Report from the NHS Medical Director was also published in October 2019.
Field testing of the proposed new standards began in 14 hospital trusts on 22 May 2019. The first stage of testing focused on measuring the “mean time in A&E”, when compared with the existing four-hour target. The field test sites have not been submitting four-hour performance data since May 2019, so an adjusted national time series was published to omit these sites’ A&E performance going back to Q1 2011/12. The time series data presented here for performance against the four-hour target excludes the field testing sites and so is comparable across months and years. Data on A&E attendances is for all trusts, including the field testing sites.
In January 2018, the NHS Improvement chief executive Ian Dalton wrote to trusts to announce a formal review of the reporting of A&E performance data. The letter referred to issues in two main areas: the reporting of urgent care (type 3) activity, and the reporting of activity from newer clinical pathways, such as ambulatory care services.
It followed the UK Statistics Authority writing to NHS England to formally raise concerns about the impact of changes to recording practice and the interpretation that should be applied. This prompted questions of whether the data was reliably measuring pressure and performance over winter.
In November 2018, the UK Statistics Authority stated that its concerns had been addressed, however, some concerns remain about the quality of performance data. For more information, see the most recent HSJ article.
NHS England data
Median waiting time in A&E and time to treatment have been calculated using provisional Emergency Care Data Set (ECDS) data since June 2020. Prior to then, they were calculated using provisional A&E Hospital Episode Statistics (HES) data. The measures used have not changed, although data quality measures are still to be developed. Provisional HES and ECDS data may be revised throughout the year. As these indicators are published on a monthly basis rather than in a time series, indicator data published for earlier months has not been revised using updated HES or ECDS data extracted in subsequent months.
NHS England notes that several organisations report data that does not meet the data quality checks required by A&E indicators, which contributes to the unusually high values observed for some measures.