How can my Trust secure the £2M NHS performance bonus for A&E flow?

The 2026 NHS performance framework ties financial bonuses directly to A&E 4-hour standard achievement, ambulance handover times, and bed occupancy rates. Trusts achieving 78%+ on the 4-hour standard with a sustained improvement trajectory are eligible. The key metric most Trusts miss is the correlation between morning discharge rates and afternoon A&E breaches.

The 2026 NHS Planning Guidance performance incentive framework links financial bonuses to three interconnected metrics: the 4-hour A&E standard (78% minimum threshold for eligibility, with additional payments for sustained improvement above 82%), ambulance handover performance (category 2 average response time and handover duration), and bed occupancy rates (sustained occupancy above 95% is a disqualifying condition). Missing any single metric removes eligibility regardless of performance on the others.

The structural reason most Trusts fall short is the morning discharge–afternoon breach correlation. When morning discharges before 12:00 constitute less than 30% of daily discharges, inpatient beds are not available to receive A&E admissions during the peak afternoon arrival window. This creates systematic 4-hour breaches between 14:00 and 19:00 — precisely when ambulance conveyances peak and walk-in volumes peak simultaneously. The incentive framework rewards sustained trajectory improvement, so a Trust trending from 73% toward 78% over 12 weeks qualifies for partial incentive payments even before crossing the threshold.

Trusts universally track the 4-hour standard as a single daily percentage. This aggregated number conceals the intraday pattern that determines whether performance is structurally fixable or operationally variable. A Trust reporting 76% daily may be achieving 91% from 07:00–13:00 and 61% from 14:00–20:00 — two entirely different operational problems with different solutions. The daily figure makes both look identical.

Similarly, bed occupancy reported as a daily average hides the critical morning nadir. If occupancy drops to 87% at 08:00 but climbs to 97% by 15:00, the average of 92% creates a false impression of managed capacity. The bonus eligibility assessment uses point-in-time occupancy measurements, which may fall in periods that are systematically worse than the daily average. Trusts that surface intraday data typically discover that 2-3 specific hours are driving the entire performance gap — an insight invisible in standard reporting.

Implement a morning discharge dashboard tracking real-time discharge numbers against the 30%-before-noon target. This single operational change, when paired with a structured bed management meeting at 09:00 reviewing overnight discharges and same-day expected discharges, reliably shifts 15-20 minutes of bed availability earlier in the day — directly reducing afternoon A&E breach probability. The dashboard needs to surface expected discharges by ward alongside actual confirmed discharges to give the bed manager a forward view.

Redesign the ambulance handover zone to enable 15-minute handovers without requiring an A&E clinical decision. Dedicated handover staff (can be band 3-4 with appropriate protocols) who complete initial observations, attach monitoring, and document clerking allows the ambulance crew to complete the handover while clinical assessment continues. This alone typically reduces handover times by 12-18 minutes, directly improving ambulance availability and reducing the corridor pressure that degrades A&E 4-hour performance. Combine with the bed occupancy and 4-hour tracking under a unified performance incentive dashboard reviewed at board level weekly.