• Over 70 per cent of hospital leaders want to keep four-hour target, HSJ survey finds
  • NHS Providers warns of “widely-held concern” changes are being driven because four-hour performance is “irrecoverable”
  • Exclusive HSJ research represents most comprehensive poll of NHS leaders on the controversial reforms

More than seven in 10 hospital trust board members want to retain the four-hour accident and emergency target, despite NHS England proposals suggesting it could be ditched next year, an exclusive HSJ survey has found. 

The survey, which represents the most comprehensive poll of senior NHS leaders on the controversial plans to reform the service’s flagship performance metric, found: 

  • Seventy-one per cent of all survey respondents “disagreed” or “strongly disagreed” that “the NHS should drop the four-hour target completely as a national performance measure” (Bar graph 4);
  • Of the 62 respondents from acute trusts, 49 per cent “disagreed” with the above statement and 22 per cent “strongly disagreed” (Bar graph 1);
  • Seventy-four per cent “agreed” or “strongly agreed” that “the four-hour target contributes to improved patient experience” (Bar graph 3); and
  • Seventy per cent “agreed” or “strongly agreed” that “the four-hour target contributes to keeping patients safe” (Bar graph 5)

Of the survey’s 104 respondents – all of which were board level in an NHS organisation – over 60 per cent of the respondents were chief executives, deputy chiefs, chief operating officers or finance directors. Just over a third (34 per cent) were chairs. Board-level respondents from over 40 per cent of the NHS’ 145 hospital trusts completed the survey (see below for full breakdown).

The stark findings sparked fresh calls from NHS Providers for a much “fuller, transparent debate”, not least to address “widely-held concerns” that changes were being driven because system leaders wanted to ditch a standard the system could no longer meet.

The comments come as the 14 trusts trialling new emergency care metrics begin the second phase of the controversial clinical standards review pilot this week. The trial was launched after NHSE published proposals in March which set out how the four-hour target could be replaced by new standards from April 2020.

There was also strong support among acute leaders for retaining the four-hour measure, but in tandem with other metrics.

Sixty-seven per cent of respondents agreed with the statement: “The NHS should introduce a new urgent and emergency care metric – but retain national reporting of the four-hour target in some form.” Just 16 per cent of respondents disagreed with this statement.

The NHS has not hit the national target – that 95 per cent of patients be seen within four hours – since July 2015. When urgent care centre performance is stripped out, England’s type-one A&E units have not hit the target since September 2012.

Siva Anandaciva, a long-standing expert on the four-hour standard and now chief analyst at The King’s Fund, told HSJ he was “not surprised there was support for the four-hour target… but I was surprised such a large majority were against dropping [it], and by the strength of feeling about keeping it”.

NHS Providers chief executive Chris Hopson said it was “understandable” that leaders “remain strongly attached to the [target]” and that they did not want to see “a lot of blood, sweat, and toil to reach the 95 per cent standard wasted”.

He added: “[NHSE and NHS Improvement] has made a strong case for updating the standard to reflect modern clinical practice. But if they are to carry that case, we need a full, wide and transparent debate involving clinicians, trust leaders, politicians and the public.

“That debate will need to directly address the widely-held concern that changes are being made because the current 95 per cent standard would cost too much to recover or is effectively now irrecoverable.”

Northumbria Healthcare Foundation Trust chief executive Jim Mackey, who oversaw an aborted attempt to reform the target during his NHS Improvement tenure, also raised concerns about the process.

He told HSJ: “The standard does need updating, so trialling new metrics is the right thing to do. However, whatever we do, we will need buy-in and understanding from staff and patients who need to see that things are better as a result of the changes.”

He added: “If there is no improvement in the conditions in departments – and things are really tough on the front line, pretty much across the board – but the numbers look better because we’ve moved to a new system, then both staff and patients will be very unhappy, and there will be consequences at some point.

“We are all aware of the workforce pressures and this really needs to be in our minds with this.”

An NHS England spokesman said: “The proposals being tested by local leaders include retaining a measure of total time in department, but one that could improve on the current single standard by ensuring that every minute is counted, rather than simply whether an attendance is over or under four hours.

“Importantly, this is as part of a suite of other measures focussed on patient outcomes and experience - an approach which this survey shows strong support for.”

The Department of Health and Social Care said: ”The government asked the NHS to review how current standards could be updated in the best interests of patients.

”The NHS has already committed to holding a public consultation, as well as their ongoing stakeholder engagement, before returning to Government with their final recommendations.”


Who did we survey?

Respondents’ organisations:


Acute trust

62 (60%)

Specialist trust

2 (2%)

Community trust

3 (3%)

Mental health trust

8 (8%)


1 (1%)

Other (largely leaders defining their orgs as integrated providers)

27 (26%)


104 (100%)

 Respondents’ roles:


Chief executive/deputy chief executive

48 (46%)

Chief operating officer

4 (4%)

Finance chief

11 (11%)


35 (34%)

Medical director

2 (2%)


1 (1%)


1 (1%)


2 (2%)


104 (100%)