A target that rewards the least sick: what Homerton’s longest waits tell us

Homerton hit its four-hour A&E target this year — but the four-hour target itself has been accused of steering hospitals towards the patients who are easiest to treat, while the sickest wait longest

The four-hour A&E target has been the headline measure of NHS emergency care for two decades.

It has also, its critics say, become part of the problem — “steering hospitals towards the least sick patients while the most vulnerable wait, and sometimes die, in the background”, in the words of the Royal College of Emergency Medicine (RCEM).

At Homerton, the tension between the two is visible in a single set of figures.

In 2025/2026 the Homerton Healthcare NHS Foundation Trust treated 81.7 per cent of A&E patients within four hours — above both the North East London benchmark and the national standard of 78 per cent — yet 972 patients were left waiting more than 12 hours for a bed, against a target of zero.

The four-hour clock matters because risk rises sharply the longer a patient waits.

A study of more than five million NHS patients in the Emergency Medicine Journal found that spending eight to 12 hours in A&E between arrival and admission raises the risk of death within 30 days by 16 per cent. The target was meant to keep that clock honest.

The college’s charge is that it can do the opposite — concentrating effort on the many quick cases that move the percentage, while the smaller number of complex patients who breach 12 hours fall outside the headline number altogether.

Dr Ian Higginson, president of the Royal College of Emergency Medicine, said: “It’s frustrating that we continue to see a lack of solutions designed to tackle the root causes of the problem at the ‘back door’ of our hospitals.

“Instead, we are fobbed off with recycled ideas that haven’t ever worked, performance data that doesn’t reflect reality, and a focus on perceived ‘quick fixes’.”

A more nuanced local picture

Does that critique describe Homerton? The trust’s own board papers suggest a more nuanced picture than gaming the figures.

A report released at a public meeting on 20 May 2026 described performance across the year as strong, with January the worst month, when four-hour performance fell to 78.8 per cent as higher admissions and delays meant patients were moved out of A&E and into wards. A targeted review saw improvements by February.

Board discussions linked the longest delays primarily to patient flow, discharge delays, rising demand and the increasing complexity of patients requiring admission, rather than to a failure to prioritise emergency care.

In other words, the 972 longest waits were less a symptom of the target’s perverse incentives than of pressure further down the line — at the ‘back door’ that Dr Higginson describes.

The clearest evidence of that pressure is in the beds. One in six was occupied by a patient who was medically ready to leave but could not be discharged — held up waiting for social care, a care home place or community support.

Against a target of 4 per cent, Homerton ran at more than four times that figure for most of 2025/2026, peaking at 18 per cent in February.

When patients who are ready to leave cannot be discharged, beds stay occupied and capacity for new admissions is squeezed — which is how a hospital can hit its four-hour target and still leave 972 people waiting more than half a day for a bed.

A spokesperson for the trust said: “We are proud of the progress we’ve made this year in improving care for our patients, particularly given the sustained pressure on emergency services. Our teams have worked incredibly hard, alongside various system partners, to deliver timely, high-quality care.

“While demand continues to grow and there is more to do, this progress reflects a genuine system effort to improve access, flow and patient experience. We remain focused on working together to build on this and ensure our services continue to meet the needs of our local community.”

In a statement to the Citizen, Hackney Mayor Zoë Garbett said: “I spent years in the NHS fighting health inequalities, so seeing Homerton meet its emergency department targets is really welcome news.

“At the same time, we know our health service is massively underfunded and overcapacity.

“Whether hospitals or local councils, we all face increasing service needs due to poverty and socially created health problems, yet the government provides insufficient resources to address these growing problems. These problems are systemic and require systemic solutions.

“We also know that only around 20 per cent of someone’s health outcomes are attributed to the healthcare they can access.

“This means that the majority of someone’s health, wellbeing and ability to thrive depends on wider determinants like housing, food security, poverty, education and employment. It’s those factors that I’m looking to address in my role, to improve health in Hackney.”