Introduction

Emergency departments (EDs) are a critical component of the urgent and emergency care system. They respond to those patients most in need of acute NHS care, often at points of crisis in their lives, and play an important role in shaping public perception about how the NHS is faring.

The challenges facing EDs today should be well understood, with demand outstripping capacity, long wait times and overcrowded departments. Poor hospital flow results in the unacceptable experiences of corridor care and ambulance delays. This, in turn, leads to delay-related harm – often to our most vulnerable patients – and a poor working environment for staff.

High-performing urgent and emergency care pathways depend on the whole system working effectively around the clock, 24 hours a day, 7 days a week.

Additional guidance will follow to set out how different components of the wider urgent and emergency care (UEC) system should support improvements in flow, including:

• urgent community services
• standards for the first 72 hours of hospital care
• 7-day working standards
• mental health EDs
• the development of neighbourhood health
• specific work on frailty and children and young people (CYP) pathways

This will help to establish the ED as a ‘destination rather than a default’, with patients directed earlier in their pathway to the most appropriate care for their needs. This should form part of an overall system effort to improve urgent and emergency care performance towards the constitutional pledge that at least 95% of patients attending A&E should be admitted, transferred, or discharged within 4 hours of arrival.

The purpose of this publication is to:

• focus on elements within the ED’s control
• set out opportunities for good practice in internal ED pathways

This publication should be read in conjunction with other guidance involving all elements of the UEC pathway.

This guidance applies to all age groups, ensuring that the needs of adults and children and young people are appropriately considered within ED pathways.

The principles of clinical care within an emergency department

There are 5 key principles:

• the ED must be prioritised for those patients who are in most need of emergency medical care
• overcrowding increases risk in the ED environment, making it harder to identify and clinically prioritise the sickest patients and those with vulnerabilities (for example, frail, newborns, those with learning difficulties or mental health conditions)
• overcrowding also increases the inefficiency within UEC pathways, driving up staffing levels and pressures, and causing more delays
• patients requiring emergency medical care, whether to be admitted or discharged from the ED, should receive care in an appropriate setting and not be put at risk of delay-related harm with undue waits for investigation, treatment, specialty care or admission
• the ED team cannot deliver effective and high-quality care without engagement and leadership from the whole hospital and effective patient flow and discharge pathways from all specialty teams

The patient’s perspective

Feedback from patient groups and previous patient engagement exercises (that is, London’s ‘dialogue and deliberation’ exercise and the patient attitudes survey) have highlighted the following among patient priorities when receiving emergency or urgent care.

It is important to note that children and young people and those with frailty may have different needs and experiences that must also be taken into account (see further considerations for children and young people in appendix 1).

Recommended elements of the emergency department

To meet these principles and deliver care that matches patient needs, it is important we work to ensure the ED has adequate facilities to assess and manage emergency patients – those who require the skills of the emergency physician and the resources of an ED.

By using potential areas of care according to demand, we can help ensure that patients who need the specific skills of emergency medicine are prioritised for this care.

In EDs that see adults, children and young people, it is essential that the commissioning, design and layout support the needs of all groups equitably.

Some departments will be providing patient care under the same principles but not in the exact configurations described; this publication is not intended to disrupt these pathways.

Not all the recommended elements of this publication will be immediately available or necessary for existing departments, and some departments may deliver the standards of care through different pathways. However, it is expected that the principles of this document should form part of the ongoing improvement strategy for emergency care within a trust.

Emergency and urgent care pathways by acuity and time

Image text:

Emergency ambulance or walk in

Up to 15 minutes
A horizontal acuity scale runs from low to high:

• low acuity: initial assessment including streaming and redirection
• high acuity: rapid assessment and treatment (RAT) – ED senior assessment as required

Up to 4 hours
A horizontal acuity scale runs from low to high. Services are arranged in order of increasing acuity:

• lowest acuity: urgent treatment centre (UTC) – minor illness
• ED/UTC – minor injury
• ED – ambulatory/seated
• ED – cubicles
• highest acuity: ED – resus

Emergency or specialist pathways

Up to 12 hours:

• extended emergency medicine ambulatory care (EEMAC)*
• specialty same day emergency care (SDEC)

Shown as between up to 12 hours and after 12 hours:

• paediatric assessment units (PAU)
• clinical decision units (CDUs)
• community services (hospital at home, virtual ward)

After 12 hours:

• adult acute assessment units
• specialist unit (critical care unit, hyper-acute stroke unit)
• inpatient wards

*This may also be referred to as a short stay unit in children and young people settings and may be hosted in a PAU.

The emergency department – key elements to support care

Single point of access (pre-hospital)

Early clinical support for patients with urgent and emergency care needs, including those in care homes or other community settings, can be beneficial. ED clinicians involved in these services are also often involved in recognising the care needs of high-intensity users of the health service.

Systems and trusts should recognise and support ED clinicians undertaking these roles. This includes supporting clinicians to provide specialist advice regarding frail patients or young infants, for example.

Front door streaming, triage and redirecting patients requiring urgent care

Patients typically present at, or are brought to, the ED either through ‘walk-in’ pathways or by ambulance. These patients then require an initial assessment to prioritise their care and determine the best area where this care can be provided.

Patients requiring the care of the ED should be immediately streamed to that area, while patients who do not need this level of care should be streamed to an urgent treatment centre (UTC) or minor illness or injury area, ideally co-located (a short walking distance between departments) with the ED. This must apply to all ages, including children and young people.

It is recognised that some departments will be using redirection to off-site units, and these should continue as appropriate – but the principle should be that only those patients who need emergency care should remain in the ED.

Referrals from healthcare professionals that require the skills of emergency medicine will go to the ED, but those who do not need this level of care may be appropriate for referral to the UTC.

Timed appointments may be appropriate for patients streamed to the urgent care areas. Minor injury streams may be located within the ED or within a UTC and, in the latter case, patients may still be cared for by emergency physicians.

Other receiving areas, such as SDEC, frailty units or assessment units, should continue to be used for those patients who need the skills of relevant specialties, including acute medicine and acute paediatric services. These areas should be optimised in line with common principles of early consultant review, early investigation and prompt specialty input as set out in The Model Acute Pathway: standards for care of acutely unwell patients in their first 72 hours in hospital and Facing the Future standards for acute paediatric care (see appendices for key guidance documents).

Digital support mechanisms for streaming and triage processes, including AI, are currently being explored and evaluated for clinical safety, effectiveness and productivity potential. Trusts are encouraged to support these innovations as they are introduced.

There should not be bedded care in minor injury units, UTCs, rapid assessment and treatment (RAT) or ambulatory majors. Patients requiring beds in these areas should be moved to areas that do support bedded care. 

Extended emergency medicine ambulatory care

Some patients can be appropriately investigated and managed under emergency medicine with an extended ED stay: that is, in an extended emergency medicine ambulatory care area (EEMAC) for adults and an equivalent for children and young people.

These facilities should be reserved for patients who are identified as requiring care, investigation or treatments, meaning the patient is likely to be in the ED for over 4 hours and, following this period of care, would then be discharged. Only patients with a specific need that falls within the scope of emergency medicine practice should be admitted to an EEMAC area for ongoing care. For children and young people, the equivalent to EEMAC facilities are often paediatric assessment units (PAUs) or short stay units (which may sit either within or outside the ED).

The EEMAC area should have appropriate skill mix, space and facilities to continue this care and operate on the expectation that patients transferred to this area are expected to conclude their clinical care within 8 hours (following a maximum period of 4 hours within ED). This would give a total maximum length of stay within the department of 12 hours (4 hours + 8 hours).

Patients should not be streamed directly to EEMAC. Instead, they should be initially assessed within the ED, and only then have their care continued within an EEMAC facility for the remainder of their treatment plan, on the reasonable expectation that they will be discharged at the end of their episode of care under emergency medicine. Specific guidance for adults is available in the EEMAC operating principles.

Some departments also have separate appropriate bedded areas, where patients are admitted under emergency medicine care for a period, usually up to 24 hours. Other departments may also find benefit from this model of care, determined by an assessment of their local population and hospital processes, estates and staffing models.

For children and young people, many departments have established links between emergency medicine and paediatric departments to provide extended emergency care. Where these links do not exist, extended ambulatory care areas should be made available for appropriate patient cohorts needing:

• additional observation
• treatments
• diagnostics under the supervision of senior decision-makers with the necessary paediatric competencies

In some centres, these patients remain under the care of the emergency team, but in others this role is undertaken by the paediatric team in the PAU or equivalent.

For all ages, it is important that there is appropriate capacity, either in an EEMAC or PAU, to deliver focused and patient-centred care that improves patients’ experiences without unnecessary admissions.

Leadership

It is important that we support our staff and colleagues in the development of this work, and that leadership across a department, trust and the wider system accepts responsibility for ED flow.

The need for capacity and demand planning over a 24-hour period will be a vital part of this work. We will work with the Royal College of Emergency Medicine, the Royal College of Nursing, the Royal College of Paediatrics and Child Health and other stakeholders to review how we support leadership roles for both managerial and clinical leads across all services that are part of urgent and emergency care.

Culture across the whole system will be an important aspect of this.

Applying the elements in practice

1. Front door, urgent care streaming and redirection

Senior nurses or clinicians, undertaking streaming and initial assessment at the ED front door, should use digital tools to support streaming and redirection and will rapidly stream patients requiring urgent care and treatment into urgent care pathways, or into ED if emergency medicine oversight is required.

Trusts should aim to meet the principle of an initial assessment within 15 minutes of arrival. Staff need appropriate training in recognised safeguarding or vulnerability issues in patients who may need input, even if they appear to be low acuity.

Patients who do not require urgent and emergency care may be referred back to primary care or to planned care services.

Patients should be streamed, where appropriate, to urgent care pathways for minor injuries and minor illnesses that are:

• urgent but not life- or limb-threatening
• expected to be treated and discharged within 4 hours

Co-located UTCs (sites a short walking distance away) should have consistent opening times across a 7-day week, typically 24 hours, and/or aligned to local demand across the whole urgent and emergency system.

Trusts should consider connectivity between the ED front door and community single point of access (SPoA), 999 and 111 to enhance opportunities for admission avoidance and redirection.

Effective workforce skill mix across EDs, UTCs, and minor illnesses and minor injuries areas, ideally with rotational roles, will enable urgent care facilities to work at the top of their capabilities and confidence in responding to higher acuity demand.

Type 1 EDs that do not yet have a co-located UTC should implement a streaming function to safely redirect care to appropriate urgent care alternatives off-site, with an agreed care plan (for example, booked appointment or referral options for urgent care). Sites should progress to co-located urgent treatment centres wherever possible, including facilities offering 24/7 care for all ages, unless an effective alternative model is already in place to meet local need. UTCs must collaborate with the EDs.

For further information, see the Principles and standards for UTCs

Ensuring success: capabilities and enablers

Many components of the model ED will already be in place, but significant variation remains across the country – and this can differ by time of day and day of week.

Every ED will need the opportunity to:

• baseline their current operating model and configuration against the key elements outlined in this publication
• identify gaps
• develop plans for improvement

Providers will need to begin work on improvement plans that include demand and capacity modelling to inform alignment with this guidance as soon as possible, with the intention to put this fully into operation from the 2026/27 financial year.

Implementation will need to be supported by an aligned workforce, accurate counting and coding and modern estate plans and, as a minimum, include consideration of the key enablers and capabilities detailed in this section.

Review of current counting and coding practice in the emergency department

To assess the effective and appropriate area use within the ED and ensure consistency of reporting across the country, a review of counting and coding will begin in the first quarter of 2026. This will include:

• benchmarking of current practice across EDs in England
• a national review of existing guidance
• associated modelling and scenarios to support change
• recommendations to support acute providers to ensure accurate ED coding

This work will culminate in the publication of revised and simplified guidance later in 2026. To ensure ongoing appropriate use of the EEMAC area, there will also be recommendations of future audit criteria, such as unwarranted conversion rates to inpatient admission.

Site-level data

To improve patient care and experience in line with this publication, all acute hospitals should ensure they have regular, high-quality site-level data across their EDs, disaggregated for adults and children and young people.

For clinical and operational leaders, site-level data will enable better insight and control over ED processes and help identify unwarranted variation.

Urgent and emergency care financial incentives

Further work to incentivise effective use of the model ED and avoid unnecessary conveyance and admission to hospital has begun.

From 2026/27, a new blended payment model for UEC will be introduced. Providers and commissioners will agree planned levels of UEC activity for the year ahead, and payment will be based on a fixed amount (price x planned activity).

To ensure that providers are appropriately reimbursed for UEC activity, both ED and admitted care, a 20% variable payment will apply for activity in year that is above or below plan, as well as a break-glass clause if activity significantly varies from planned levels.

As part of this, the proposal is to apply the UEC blended payment to specialty SDEC in 2026/27, using locally agreed prices (supported by any national guide price). This will help ensure that activity uses the same payment approach.

As this guidance and EEMAC principles are implemented, the UEC payment model will be reviewed. The proposed price has been set based on current local prices and would apply to specialty-based activity designed to avoid a non-elective admission. Local prices should be set for other same-day pathways and used for both fixed and variable payments.

UEC capital programme funding will be allocated through ICBs, with the expectation that it will be used to make material improvements in performance against the 4-hour emergency care and/or Category 2 ambulance response time constitutional standards.

Schemes which support the implementation of high-performing pathways as outlined in this publication will be prioritised, including but not limited to:

• ED refurbishment to support extended ED care, including children and young people in appropriate areas (such as PAUs)
• urgent treatment centres (UTCs) co-located with EDs, with appropriate all-age facilities
• same day emergency care (SDEC) facilities
• acute receiving areas
• mental health emergency departments co-located with EDs

Getting It Right First Time improvement offer

To support improved performance in UEC for both adults and children and young people, NHS England has simplified and strengthened a deployable improvement offer, with teams now operating under the single brand of Getting It Right First Time (GIRFT).

The improvement offer is clinically led, data-driven and operationally enabled, providing intensive support to organisations that most need it and to trusts with the potential to make further improvements this year.

The model ED will be a priority focus area for GIRFT.

Appendix 1: Considerations for children and young people

This appendix sets out in more detail the considerations that apply to EDs where under-18s are assessed or treated.

Although some local models may define the core paediatric cohort as 0 to 16 years, clear, safe pathways should exist for young people aged 16 to 18, irrespective of local age-based service configurations.

In addition, services should consider the needs of young people with complex medical needs (who may be technology dependent) and those with learning disabilities or autism, extending support up to 25 years of age where appropriate to ensure equitable care.

The patient’s experience

As part of the NHS Youth Forum’s work on hospital design (see NHS Youth Forum new hospitals report), young people shared their experiences and priorities for creating environments that feel safe, welcoming and supportive. Their feedback highlights what matters most when children and young people attend EDs.

Applying the principles of clinical care within an emergency department to children and young people

The following principles expand on the all-age principles in introduction. They should be read in conjunction with Facing the Future standards for children and young people in emergency care

1. The ED should be prioritised for babies, children and young people who require emergency care that cannot be safely delivered elsewhere. High-performing paediatric urgent and emergency care relies on integrated system working 24/7, including:

• single point of access (SPoA)
• paediatric clinical assessment service (PCAS)
• primary care clinical advice
• rapid access clinics
• children and adolescent mental health services (CAMHS)
• virtual wards (also known as hospital at home).

Pre-hospital navigation is critical to identify and maximise safe alternative pathways to the ED for minor illness and injury, and children and young people should be directed to the most appropriate setting.

Where children and young people with minor injuries can be treated within the ED, while meeting standards of care and performance, this practice should continue. Where this is not occurring, options for referring children and young people to urgent treatment centres (UTCs), minor injury units (MIU) and other areas should be considered but must meet the needs of children and young people.

2. Overcrowding in EDs increases clinical risk and makes it harder to maintain robust systems to safely recognise and respond to critically ill children and young people and those with hidden vulnerabilities (for example, safeguarding and mental health conditions). It also places significant strain on staff, causing stress, fatigue, moral distress and workload pressures that can undermine safe, compassionate care and increase turnover.

EDs must maintain safe staffing levels (as detailed in the recommendations of Facing the Future: standards for children and young people in emergency care) and child-appropriate environments to minimise harm and distress for children and young people and families, recognising the heightened vulnerability of infants, neurodivergent children and young people and those with safeguarding needs.

3. Efficient streaming, escalation and flow management are essential to maintain safety and experience during children and young people’s ED attendance. Escalation of a patient must include both clinical deterioration and wider safeguarding or welfare concerns. Timely engagement from social care, mental health services and community provision is critical to identify a safe and appropriate destination for discharge, recognising that children and young people cannot legally be discharged from paediatric ED unless there is a safe destination.

4. EDs must have clear oversight and escalation processes for times when children and young people demand exceeds capacity and should implement and regularly test paediatric‑specific escalation standard operating procedures (SOPs), including:

• early senior oversight
• triggers for internal escalation
• full‑capacity protocols
• surge actions
• safe options for transfers or diverts, where appropriate

These plans must be designed with paediatric expertise, reflect local and regional paediatric capacity, and ensure that any escalation action maintains safety, continuity of care and safeguarding oversight for children and young people.

5. Children and young people should receive care in an ED environment with a secure access point and audio-visual separation from adult patients. It should be designed for their age, developmental needs and family context, with timely access to diagnostics, treatment, and specialty input. Providers should consider using capital allocations to create spaces that feel safe and welcoming and include areas:

• for children and young people with complex needs, neurodiverse conditions and mental health presentations
• with breastfeeding and nappy changing facilities
• age-appropriate food and drink
• provision of play services
• that allow parents or carers to stay comfortably with their child

Trust and ICB boards should ensure that the ED environment does not allow any kind of corridor care.

6. Paediatric emergency care must uphold safeguarding standards and involve families in decision-making, ensuring dignity, clear communication, and emotional support throughout the ED journey. Staff must have access to supervision and senior support when managing complex or distressing safeguarding situations.

7. Children and young people with mental health needs must receive parity of care in an appropriate secure safe space. Mental health assessment and treatment should begin in parallel with physical healthcare with rapid CAMHS or liaison psychiatry assessment (ideally within 1 hour) with 24/7 coverage. Staff should be trained in trauma-informed practice and de-escalation techniques. Depending on local need, estate demand and safety considerations, under 18s access to mental health emergency departments (also known as crisis assessment centres) must be considered as part of local planning. Systems must have escalation protocols in place to support those with complex psychosocial needs (who may be stranded ) where a rapid, multiagency response to enable their discharge is required.

8. Improving paediatric ED flow relies on co-ordinated action across the whole hospital and wider system, including timely engagement from paediatric specialties, CAMHS, hospital flow teams, community paediatrics and social care. Providers, ICBs and local authorities should jointly map and maintain clear paediatric UEC pathways – covering inpatient capacity, community provision, mental health services and safe discharge routes – to ensure children and young people can move efficiently through ED and only be discharged to an appropriate, safe destination.

Appendix 2: Related resources

Emergency care standards

• Facing the Future: standards for children and young people in emergency care
• Royal College of Emergency Medicine: guidelines for the provision of emergency medical services  

Urgent and emergency care system guidance

• Urgent treatment centres – principles and standards
• Neighbourhood health guidelines 2025/26
• Paediatric same day emergency care (SDEC)
• National paediatric early warning system (PEWS)
• Safeguarding children, young people and adults at risk in the NHS
• Virtual wards operational framework

Mental health and crisis care

• Crisis and acute mental health services
• Supporting children and young people (CYP) with mental health needs in acute paediatric settings: a framework for systems
• Urgent and emergency mental health care for children and young people: national implementation guidance
• Mental health winter action cards (Futures collaboration platform login required)
• Mental health case studies (Futures collaboration platform login required)

Workforce, safety and quality

• Royal College of Paediatrics and Child Health: Facing the Future: standards for children and young people in emergency care

Improvement

• Getting It Right First Time (GIRFT)

Patient engagement and experience

• Youth forum new hospitals report 2024-25

Publication reference: PRN02373