Intended for healthcare professionals

Head To Head

Should we scrap the target of a maximum four hour wait in emergency departments?

BMJ 2017; 359 doi: (Published 25 October 2017) Cite this as: BMJ 2017;359:j4857
  1. Peter Campbell, independent public health consultant1,
  2. Adrian Boyle, consultant2,
  3. Ian Higginson, consultant3
  1. 1Institute of Public Health, University of Heidelberg, Germany
  2. 2Emergency Department, Cambridge University Hospitals Foundation Trust, Cambridge, UK
  3. 3Emergency Department, Plymouth Hospitals NHS Trust, Plymouth, UK
  1. Correspondence to: P Campbell peterinwork{at}, A Boyle adrian.boyle{at}

Pressure to achieve arbitrary targets is not a valid improvement strategy and leads to perverse incentives and use of resources, claims Peter Campbell, but Adrian Boyle and Ian Higginson say no alternative exists to keep emergency departments working

Yes—Peter Campbell

Consulting on health system projects in numerous developing countries has taught me that whenever health workers fear targets, sustained improvements in care are unlikely. Pressurising NHS emergency departments in England to see, treat, and admit or discharge patients within four hours exemplifies this.1

We’ve had 13 years: surely enough time to hit the four hour mark sustainably? Yet this year, as more patients wait longer,1 the health secretary reinterpreted the target to include only urgent cases, not all attendances.2 Hospitals are relieved: by redefining “urgent” the target can be met and funding secured.

Although supporters of the target argue that emergency departments have been strengthened by investment and that waiting times are under control, the target's destructive consequences negate these gains.

Undeserved rewards

In the last three months of 2002, well before financial incentives were introduced for hitting targets, almost 7% of emergency departments already managed 95% of patients within four hours3 so rewarding them was unnecessary. And, without needing incentive linked targets, organisational reforms alone have reduced waiting times.4

Masterful managers manipulate. The National Audit Office admits that patients triaged into parallel acute assessment units aren't counted5: so in reality patients wait longer than reported. Patients have been “stacked” in ambulances6 or hurriedly admitted near the deadline.78Processes have been introduced that favour younger patients at the expense …

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