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Views & Reviews

The good, the bad, and the four hour target

BMJ 2008; 337 doi: (Published 17 July 2008) Cite this as: BMJ 2008;337:a195
  1. James Orr, specialty registrar 1, West of Scotland
  1. j.orr{at}

    The NHS’s four hour target for being treated in accident and emergency departments has dramatically changed the way unscheduled care services are run. It aims to improve the “patient journey” by emphasising the length of time it takes for a patient to be seen, assessed, treated, and “disposed of” by the emergency department. However, the effects of this target driven system have wide reaching implications throughout the hospital. I believe that ascribing too much importance to the four hour rule may, instead of benefiting patients, as is intended, actually harm them and thus contradicts the first ethical principle of medicine.

    Hippocrates described the four ethical principles of medical practice in about 400 bc, a sort of “moral compass” for doctors even today. The first and most important of these is non-maleficence: “above all else, do no harm.” One would be hard pushed to find a clinician, even in 2008, who would disagree with such noble logic. Unfortunately, we are in danger of unwittingly failing our patients and the profession if we allow …

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