Intended for healthcare professionals

Letters Four hour target in emergency departments

Goodhart’s law: when waiting times became a target, they stopped being a good measure

BMJ 2017; 359 doi: (Published 27 November 2017) Cite this as: BMJ 2017;359:j5425
  1. S Michael Crawford, clinical lead for research
  1. Airedale NHS Foundation Trust, Keighley BD20 6TD, UK
  1. s.m.crawford{at}

At the beginning of this century, Tony Blair, then prime minister, announced that health expenditure would be increased. This was met with expressions of concern from the Treasury. I have a clear recollection of Alan Milburn, then secretary of state for health, telling a television news reporter that the NHS would willingly meet Treasury demands for the NHS to meet targets. This is the background for the development of targets for emergency departments and other services.

In The BMJ Campbell argues, and Boyle and Higginson confirm, that emergency departments have been able to invest to ensure that the target is met.1 Similarly, targets for surgical waiting times and cancer referral have encouraged investment in those services.

No targets were set for mental health services. So even in 2005, when we knew that mental health policies were not being implemented,2 a major health trust “was asked to make savings to make up for budget overspends by other trusts.”3 Underprovision of mental health services remains a problem. That is how the meeting of targets could have been funded.

The economist Charles Goodhart is eponymously associated with a law that is summarised as, “When a measure becomes a target, it ceases to be a good measure.” 4 Waiting times were a good way to measure provision of healthcare but after targets were set, this ceased to be the case.


  • Competing interests: None declared.


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