A&E waiting times

Analysing data on waiting times in A&E, we look at the commitment to a maximum four-hour wait.

Indicator

Last updated: 04/05/2022

Access and waiting times
Emergency care

Background

The four-hour A&E waiting time target is a pledge set out in the Handbook to the NHS Constitution. The operational standard is that at least 95% of patients attending A&E should be admitted, transferred or discharged within four hours.

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 has consulted on the proposed new standards, and the response to the consultation states that the new standards will be rolled out. The existing four-hour target remains in force until any new standards are announced. Read our blog for more information about the proposed A&E targets.

This indicator explores breaches of the four-hour A&E target since 2011 and other urgent and emergency care standards. 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.


How has performance against the four-hour A&E target changed over time? 29/04/2022

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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 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 since then. 

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 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. 

Further into the Covid-19 pandemic, the number of A&E attendances has returned to pre-pandemic levels and performance against the four-hour target has declined. In Q4 2021/22 there were around 5.9 million A&E attendances. Waiting time performance worsened for all types of A&E attendances: 66% for type 1 attendances and 96% of patients attending type 2&3 departments – 13% percentage points lower than Q4 2019/20.

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 Q2 2020/21 and Q3 2021/22, the total number of booked attendances at A&E increased from 43,980 to 226,567 (data not shown). In Q3 2021/22, this represented only 3.7% of total A&E attendances.


How has monthly performance against the four-hour A&E target changed over time? 29/04/2022

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Performance against the four-hour A&E target tends to be higher in the summer months and worse in the winter. The impact of winter pressures can been seen going back to 2011/12; 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 with more complex care needs and a greater number of people requiring emergency admission to hospital.

In previous years, drops in performance have been observed from October onwards, and performance recovers at least partially by April the following year. Performance in 2021/22 is an exception to this trend. Between October 2021 and March 2022 performance declined to an all-time low of 60% rather than recover. 


How has the median time spent in A&E changed over time? 29/04/2022

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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 has increased to a new peak of 3 hours 8 minutes in October 2021. In February 2022, the median wait time for all patients was 3 hours 6 minutes.

For patients who required admission to hospital, the median A&E waiting time remained below four hours until September 2019. Note that the four-hour A&E target is for 95% of patients to be seen in four hours, whereas the median represents 50% of patients. 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 between a decision is made to admit them and being admitted) in the winter of 2019. In June 2020, the median waiting time for admitted patients fell to 3 hours 30 minutes, before increasing to a new high of 5 hours 29 minutes in October 2021. In February 2022, the median waiting time for admitted patients remained high at 5 hours 31 minutes.

Median waits are routinely published by NHS Digital each month, but the new A&E standards will measure the mean time in A&E for admitted and non-admitted patients (not currently published). It is worth noting that the data provided by NHS Digital is provisional and has data quality issues (see ‘About this data’ for more information).


How long do people wait for treatment to begin in A&E? 29/04/2022

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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. This chart shows that the median treatment waiting time changed little until February 2020, when it started to fluctuate, ranging from a low of 24 minutes in April 2020 to a high of 1 hour 19 minutes in September 2021. 

The 95th percentile value – that is, waiting times for the 5% of 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 sharply to 2 hours 1 minute, before increasing to 5 hours 34 minutes in October 2021. It is worth noting that this measure can be sensitive to data quality issues.

The Review of NHS Access Standards intends to measure the time to emergency treatment for critically ill and injured patients. It proposes introducing a package of treatment to be completed in the first hour after arrival for life-threatening conditions such as stroke, heart attack, major trauma, asthma and acute physiological deterioration (including sepsis).


Trolley waits: how long do people wait to be admitted onto a hospital ward? 29/04/2022

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For patients that require admission to a hospital ward, either from A&E or via other routes, the time they wait between the doctor deciding that they should be admitted for treatment and the patient arriving on the ward is an important measure of safety. The Royal College of Emergency Medicine estimated that overcrowding and extreme delays led to 4,519 excess deaths in England in 2020/21. 

The numbers of patients waiting over four hours between the decision to admit and admission tend to be the highest in the winter months and have increased over time. In March 2022, 136,297 patients waited over four hours from decision to admission, 27% of all patients. This is worse than previous years: performance was 10% in March 2021, 12% in March 2020 and 11% in March 2019.

The bars on the chart show the number of accident and emergency patients who waited over 12 hours from the decision they need treatment to admission to a hospital ward. In March 2022, 1 in 22 people waited over 12 hours from decision to admission. There were 22,506 extreme waits in March 2022 – 33 times higher than March 2021, and 68 times higher than March 2019. The Royal College of Emergency Medicine comments that “twelve-hour stays were not a thing 10 years ago”, they now seem to be a feature of accident and emergency care.

It is worth noting that data is not currently published on the number of patients spending over 12 hours from arrival at A&E to admission. The number of long waits in A&E could be greater than the data published, which only measures from the point at which a decision is made to admit a patient.   


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 refers 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 Digital 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 have not been revised using updated HES or ECDS data extracted in subsequent months.

NHS Digital 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.

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