Intended for healthcare professionals

Letters Four hour emergency target

Targets still lead care in emergency departments

BMJ 2010; 341 doi: (Published 06 July 2010) Cite this as: BMJ 2010;341:c3579
  1. Suzanne Mason, director1,
  2. Jon Nicholl, director of research and deputy dean2,
  3. Thomas Locker, consultant in emergency medicine3
  1. 1Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA
  2. 2Medical Care Research Unit, Health Services Research, School of Health and Related Research (ScHARR)
  3. 3Barnsley District Hospital NHS Foundation Trust, Barnsley S75 2EP
  1. s.mason{at}

    The UK four hour standard for processing patients attending emergency departments was introduced at 90% in 2004 and has sat at 98% since 2005. We have shown that the effect of the target is not uniform—patients admitted to hospital from the emergency department were affected most by a “spike” in activity during the last 20 minutes of the four hours, which affected 12.3% of admitted patients and 3.6% of discharged patients in 2004.1

    We investigated whether this spike was still occurring nationally. We analysed 12.2 million new patient episodes at English emergency departments from hospital episode statistics data for 2008-9. The figure shows that the spike is still present and larger than in 2004, affecting 30.7% of admitted patients and 10.5% of discharged patients.


    Distribution of time spent by patients in emergency departments by admission and discharge, 2008-9

    Although many in the specialty of emergency medicine support the benefits that the four hour target has brought, these results suggest that they are not being experienced by all patients, and that processes throughout the hospital and wider healthcare system may not have improved to accommodate it. If acute trusts have such difficulty achieving this target, perhaps a different approach, such as the one announced by the new government of a reduction to 95%, is more appropriate.

    Good evidence based indicators of quality in emergency medicine need development.2 We have no evidence that the 98% four hour target benefits clinical care, and our findings suggest that it has encouraged target led rather than needs led care.


    Cite this as: BMJ 2010;341:c3579


    • Competing interests: None declared.