Then, in 2018, NHS England began a review of this standard and proposed replacing it with a new basket of standards. This was done as part of the Clinical Review of Standards Project (CRS). At the PSC we covered this proposed change in an article in early 2021.  

However, the HSJ revealed in November that the standards review has been put on hold and so the 4-hour target will remain. In a further turn of events, NHSE’s 2023-24 planning guidance has introduced a lowered interim target of 76% compliance, significantly below the official target of 95%.  

At The PSC, we believe that the 4-hour standard is still as important as ever, and that a renewed focus will lead to improved outcomes for patients and clinicians alike. Segments of the CRS should also be carried forward to help give a holistic view of overall Urgent and Emergency Care performance, but the four-hour A&E target will ultimately be key to help reduce operational pressures and improve patient outcomes across the board. 

In some ways, the 4-hr target works...  

The Department of Health initially set the target of a maximum 4-hour wait in A&E from arrival to admission, transfer, or discharge in 2004 during Blair's premiership with the goal of reducing waiting times and controlling overcrowding.  This target was initially set at 98% compliance, and then lowered to 95% in 2010.  

Studies have shown that this standard has had a positive impact on patient care. The standard has been associated with better hospital bed management (according to the British Medical Journal) and reduces patient waiting times and mortality rates (according to the IFS). For example, patient mortality within a year of visiting A&E reduced by 0.3 percentage points, representing 15,000 fewer deaths in 2012-2013.  

NHS data also shows that in Q3 2002, 79% of patients spent less than 4 hours in A&E while in Q3 2005 (after the introduction of the targets), that level was 98%. This shows that a concerted focus on performance reaped benefits.  

We spoke with Tim Hubbard, Acting Divisional Director of Operations at Maidstone & Tunbridge Wells (MTW) NHS Trust. He said that MTW “never took its eye off the 4-hour target” and that it’s the first indicator they look at in their daily huddle. For MTW, the 4-hour target has been and remains a clear driver of improvement.  

But it has significant limitations...  

Former NHS chief Lord Sir Simon Stevens, the original driving force of the CRS, viewed the target as a blunt instrument that needed retiring. It does not measure total waiting times, instead only looking at performance within the first 4 hours. 

 It also misses a more nuanced assessment of the quality of care and clinical management within the first 4 hours. For example, it doesn't take into account whether a patient is appropriately directed to same day emergency care, or whether a frail elderly patient is appropriately cared for by a front-door frailty service on their arrival to hospital.  

Finally, the standard is actually not very well understood by patients. The target is that patients should be admitted, transferred, or discharged within 4 hours, patients misunderstand this and incorrectly assume that they will be seen within 4 hours. This assumption is easy to understand, yet it highlights that even this singular target is prone to misunderstandings. 

17% of all admissions to Type 1 A&Es between January and December 2018 occurred between 3 hours 50 minutes and 4 hours, prompting criticism that the 4-hour target has encouraged the NHS to ‘treat the target rather than the patient’. Evidence suggests that hospital processes, rather than clinical judgement, are responsible for this spike in admissions or discharge in the immediate period before a patient breaches the standard. NHS England analysis has revealed this phenomenon, which is demonstrated in the graph below: 

Fig 1: Number of admissions to A&E between January and December 2018 

Source: NHS England analysis of Secondary Uses Services (SUS) data

We also spoke with James Ray, National Clinical Advisor for NHS 111 First and Emergency Medicine Consultant at Oxford University Hospitals. His view was that the 4-hour target was excellent when it came in but now clinicians can be desensitised to seeing poor performance against the standard, so it acts as less of a motivator. It also doesn’t give the whole picture of A&E performance, for example it does not convey how crowded the department is.  

The new proposal 

As part of the 2018 Clinical Review of Standards Project, a bundle of 10 new standards were introduced, as shown below. These metrics focus on different aspects of the system, providing insight into the performance of urgent and emergency care as a whole. 

In 2019, 14 NHS trusts across England piloted these standards, including Bedfordshire Hospitals NHS Foundation Trust, whose Luton & Dunstable Hospital has historically performed well against the 4-hour target, and Portsmouth Hospitals University NHS Trust, which has historically performed less well. 

There were differing views when the proposal to scrap the 4-hour target was announced, but the consensus was that the new measures would have a positive impact. The RCEM was initially strongly against the idea, but ultimately decided that a “new mindset” was needed to fix the “crisis” in urgent and emergency care. The Academy of Medical Royal Colleges, the Society of Acute Medicine, NHS Providers and patient groups including Healthwatch England expressed their support for the new proposal. 

What were the benefits of the new metrics?  

A&E performance receives pressure from many sources, such as poor pre-hospital care leading to increased admissions and wards being full which prevent patients from transferring out of A&E. The introduction of new metrics covers a much wider range of activities than the original target and encourages more coordinated working between services. The new measures offer a holistic approach by considering the system as a whole rather than just focusing on A&E departments. They are also more robust as all metrics can be viewed together so it is harder to manipulate overall performance.  

James Ray felt that the new standards had great potential. For example, he said that the 8th measure – “time between when patient is clinically ready to proceed and transfer from ED” was impactful as it is clinically-driven and the ED makes the decision. He highlighted weaknesses in another of the current standards, which tracks the number of patients waiting over 12 hours from decision to admit to being transferred. He called this a “pseudo-metric” as the timing of the decision to admit is prone to gamification. Tim Hubbard also did see value in some of the new metrics, he was particularly interested in the insights from total time in ED, percentage of ambulance handovers within 15 minutes and triage time.  

And what were the blockers? 

There are several issues which ultimately contributed to the scrapping of the new proposal. Firstly, introducing 10 new targets would mean that A&E performance becomes far more difficult to interpret, especially for non-health experts. It was unclear how the targets could be presented to help patients understand how well the NHS is performing; at the same time, it can present a confusing picture for ministers who aim to hold the NHS to account. There would also be more administrative pressure on staff as 10 metrics are harder to collect, understand and analyse than the original singular metric.  

Another strike for the CSR was the publishing of an EMJ study which showed that waiting lengths for A&E admission over 5 hours show statistically significant increases patient mortality risk which keeps increasing with longer waits. This influential study supported the 4-hour target which was due to be replaced. It is also important to consider that the new Health Secretary, Steve Barclay, has expressed that the NHS should reduce their number of targets and focus on delivery. Introducing several new targets arguably flies in the face of this agenda.  

Conclusion

Based on some of The PSC’s recent on-the-ground work in urgent and emergency care, we have seen that in the time since the CSR, a number of trusts have reduced their focus on meeting the 4-hour target as they were anticipating the new measures. As a result, a ‘performance vacuum’ has emerged, where it was unclear what should be measured, and which targets must be met.  

According to James Ray, a potentially ideal combination would include the current 4-hour standard, the new clinically ready to proceed standard and a real time 12-hour standard that is measured from attendance to hospital admission. Together, these measures would establish a more nuanced view of ED performance. 

Tim Hubbard said that there was nothing in the new metrics that we shouldn’t be focussing on, but they could never replace the 4-hour target. At The PSC, we don't think it's a coincidence that MTW has never stopped paying attention to this target and they are the 2nd best performer in A&E wait times nationally.

At the same time, the HSJ reported that the 14 trusts who piloted the new standards have reported that median wait times have increased more than at non-pilot sites. Even those Trusts who didn't formally stop tracking the 4-hour target will likely have taken their finger off the pulse because of the performance vacuum. As a result, we believe that a renewed focus on the 4-hour standard will likely mean re-establishing of robust measures and improved urgent care performance. 

Authors: Harjyot Anand and Harris Lorie, The PSC Transformation