Intended for healthcare professionals

Editor's Choice

When targets miss the mark

BMJ 2017; 359 doi: (Published 26 October 2017) Cite this as: BMJ 2017;359:j4934
  1. Richard Hurley, features and debates editor
  1. The BMJ
  1. rhurley{at}

Warnings of a looming winter crisis in the NHS are coming thicker and faster, with another just last week (doi:10.1136/bmj.j4885). It’s appropriate, then, that our latest Head to Head debate considers emergency care, a barometer of NHS performance in the cold season, and whether the “four hour wait” target has had its day.

Since 2004 this target has stipulated that emergency departments in England should see, treat, and admit or discharge most patients within that time.

“Before the target was introduced, being a sick patient in an emergency department was pretty awful,” Adrian Boyle and Ian Higginson remind us (doi:10.1136/bmj.j4857). “Emergency departments were often full, waiting times were long, and care was poor.” The target has focused resources, improved urgent care as a whole, and may have reduced deaths, they say. But their opponent, Peter Campbell, remains unconvinced. He notes that the target is not being consistently met despite its longevity. In fact, he dislikes targets altogether, pointing out that they inevitably distort care and encourage gaming. “Masterful managers manipulate,” he says. Real and sustainable improvement in A&E is more likely if payments are not linked to targets.

The effect of a different kind of target is worrying doctors and patients. The UK government promised to create a “hostile environment” for foreigners, including in the NHS, and this year it committed itself to cut net immigration to 100 000 people a year.

Clinicians now find themselves at the sharp end of policy to fulfil these promises. Starting last Monday, patients must be assessed for immigration and residency status before they receive NHS treatment in England, as our editorialists Lucinda Hiam and Martin McKee explain (doi:10.1136/bmj.j4713).

Patients deemed ineligible may have to pay upfront at 150% of the tariff—or go without care for themselves and their children. The policy also applies in services provided in the community and by charities that receive NHS funding. The Department of Health warns that doctors who treat a patient it deems ineligible could face prosecution.1 The likely result is that patients most in need will be refused care or will be deterred from presenting to health services, say Hiam and McKee.

The campaigning group Docs Not Cops set up a mock immigration checkpoint outside the Department of Health headquarters in Whitehall in protest (doi:10.1136/bmj.j4924). The policy is unfair, contradicts the NHS’s founding principle to treat people on the basis of need rather than ability to pay, and reduces doctors to border guards, the group says.


  • Follow Richard on Twitter, @rich_hurley


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