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Partha Kar: Recalibrating the four hour target

BMJ 2019; 367 doi: (Published 09 October 2019) Cite this as: BMJ 2019;367:l5878
  1. Partha Kar, consultant in diabetes and endocrinology
  1. Portsmouth Hospitals NHS Trust
  1. drparthakar{at}
    Follow Partha on Twitter: @parthaskar

It’s nearly that time of the year again—or at least it used to be. Now the drive to “improve flow” is pretty much a year round phenomenon. And what started as a well intentioned goal of ensuring that 95% of patients attending emergency departments were admitted, transferred, or discharged within four hours has become a tool for measuring the success of departments, hospitals, and trusts. The “four hour target” has become a political football, and views about its use are becoming ever more sharply polarised.

The problem, as ever, is not the target itself but the NHS’s obsession with following it like a moth to a flame. Hospital after hospital has cooked up one initiative after another, pushing the edges further, driving efficiency harder, and even taking pyjamas off quicker.

Yet, behind closed doors, few people actually say that the four hour target is achievable. Whatever clinical initiatives are involved, at the end of the day it’s a case of success or failure being judged by a number. The rare instance of success looks like a small oasis in a growing desert of missed targets—in which any failings, or otherwise, are very rarely due to lack of effort from doctors or other healthcare staff.

External agencies arrive with dark hints of “teams not working hard enough” and zany ideas with very little evidence of benefit. They open short stay units by splitting acute units, and then they merge them again. They open community wards and then close them again, all in the belief that senior presence speeds up patient flow. Ward rounds start to seem like a relentless drive to send people home. Somewhere in between, the actual joy of seeing patients and helping them improve has been lost.

If we actually look at the four hour target as a performance indicator—and we should do, given that this is now the focus of so many hospitals—then all of these initiatives have, overall, failed. You can turn a wheel only so fast. When your arrivals at the front door outstrip all capacity you’re dead in the water.

There are various reasons for this. Demand may be one factor: the NHS must be the only institution in the world where we advertise our services as awesome, promise amazing customer service, and then ask the customers not to go there and to use other options.

Another factor is funding. Some more of it may be going to hospitals, but let’s be honest: a good tranche of it goes towards funding locums doing senior shifts or simply towards more sessions for existing seniors. In the meantime, there’s very little evidence of improvements from the extra funding and very little focus on the crunch issue of social care.

Is it time to refocus? Maybe we could align the four hour target to certain areas such as “major” emergency attendances only? Or we could make it reflect the system rather than the hospital. Or, even more radically, we could try to get on top of social care issues. If not, we’re but a whisker away from most clinicians shrugging their shoulders at the latest black alert—and it’s not good for anyone concerned when “poor” performance becomes the norm.


  • Competing interests: I am national specialty adviser for diabetes with NHS England.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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