Background to the report

NHS accident and emergency (A&E) services for urgent and emergency health needs are provided by around 200 organisations such as hospitals or walk in centres in England (as at March 2026). A&Es are classified into three main types, depending on the severity of the health conditions that they can treat, with many areas providing a combination of A&E types. Type 1 A&Es treat the most complex and urgent cases.

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In 2010-11, the NHS Constitution included a maximum four-hour waiting time, aiming to have 95% of patients discharged, transferred or admitted within that time. Ninety-five percent remains the constitutional standard. However, from 2023, NHS England (NHSE) has set lower, more achievable interim targets for four-hour waits several times, including in the Delivery plan for recovering urgent and emergency care services – 2023. The latest is to achieve 85% by 2028-29. Each NHS trust has its own specific challenges and access to resources, which can affect their performance.

The NHS has found meeting the four-hour target for 95% of attendances very challenging. The last year in which it met the four-hour target nationally was in 2013-14, when it met it for 95.7% of attendances. Performance then declined to a low of 70.8% in 2022-23, before beginning to improve. In 2025-26, the NHS met the four-hour target for 74.9% of attendances.

NHSE has several means to improve performance in A&Es: at strategic level through improvement plans; by publishing national guidance for trusts to implement; and by providing support to individual trusts with improvement teams such as Getting It Right First Time.

Scope of the report

We have looked at how well patients flow through A&E into the wider hospital in England and at the support NHSE provides to trusts to improve that flow. The flow of patients is important as it affects the timeliness of an individual’s care and the capacity of A&Es to deal with other patients. This report sets out:

  • an overview of A&E services, targets and spending
  • an analysis of flow through hospitals and the factors that affect it
  • what NHSE and trusts are doing to improve performance

Video summary

Ian Wang, Senior Auditor, summarises the report’s findings.

Conclusions

The NHS is beginning to improve the performance of A&Es after the severe impact of COVID-19, but improvements have been smaller and slower than hoped. Patients are still waiting too long for the emergency care that they need. NHSE has made significant investment into A&E, but so far this has only resulted in modest gains, with the result that spending has grown without achieving equivalent improvements for A&E patients. This may indicate that the solution is not only a question of more resources, but also how those resources are deployed.

Experience to date suggests that, alongside efforts to provide care in alternate settings, success also rests on the need to effectively manage patient flow throughout the whole hospital system, enabled by electronic patient record systems and strong leadership.

The NHS will not meet the overall A&E performance standards without very substantial improvement in many Type 1 A&Es. Such improvement will require systemic intervention. Some of the main reasons for slow flow are in the control of hospitals themselves, but there is also significant potential with better integrated support for patients leaving hospital.

There are some promising initiatives locally and new national guidance, but these will not necessarily lead to the big improvements needed without NHSE providing more support to trusts to reprioritise resources and scale up the best approaches. There is not sufficient visibility or national measurement of whether patients get the right treatment at the right time once admitted to hospital, or the reasons why discharges from hospitals are delayed.

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Press release

View press release (9 Sep 2026)

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