11 Oct 2016
Area of work:

The aim that 95% of patients attending A&E should be admitted, discharged or transferred within four hours is one of the highest profile NHS targets, yet it is being consistently missed across England. Previous Nuffield Trust work has argued that although the target can be over-emphasised, struggles in meeting it are associated with deeper problems in the capacity to move patients into hospital wards. This briefing draws on theories about congestion to look at why this has become more difficult, and what can be done about it. It aims to be useful to the hospital managers and people involved in Sustainability and Transformation Plans who tackle these problems on the front line, as well as to the policymakers who oversee them.


This briefing lays out how greater speed through a system often requires more space. Looking at trusts that meet the four hour target and those furthest from meeting it, it estimates that at least 5.5% of beds need to be free for the standard to be met. Yet many hospitals are unable to provide this much of the time, making target breaches inevitable.

The paper looks at ongoing changes driving this squeeze on bed space, including mortality, the squeeze on bed space during years of austerity, rising numbers of patients with multiple conditions, and delayed discharges.

An analysis examines how bed use and patient flow change through the course of the day, drawing on Hospital Episode Statistics which track admissions and discharges. It shows that bed occupancy does not peak at midnight, when the official census of patients is carried out, but in mid morning. Meanwhile, the highest need for patients to be moved through hospital peaks at an entirely different time of day, in the evening.

With the NHS facing an unprecedented financial squeeze, the briefing looks at solutions available short of actually building enough beds to restore free space. It suggests managers should focus in particular on the minority of long-staying patients who account for a majority of bed use. Given the variation during the day, and with an increasing number of patients leaving in a matter of hours, it urges the NHS to invest in IT and management systems that can track and deal with the need for beds and patient movement in real time.

These different sections will be of interest to different people – those managing beds, those looking at local health services as a whole, and those thinking about the resources needed by the NHS nationally. The document has a hyperlinked contents page allowing readers to jump straight into different sections.

Email to a friend

Your message will be:

I thought you might be interested in this page on The Nuffield Trust website.