Does the four-hour A&E target matter?

Ambulance Ambulances can sometimes be forced to queue outside A&E

The A&E target certainly made a big difference when it was first introduced. Waits of 12 hours were not unheard of before the four-hour target came into force in England a decade ago.

But like all targets, it is a blunt tool too.

Patients undoubtedly enjoy much shorter waits than they did - even during these last few months.

When the target was brought in nearly twice as many patients were waiting longer than four hours than the numbers during the peak this winter.

However, there are ways to play the system.

Two of the most common are getting ambulances to queue before hospital staff will take their patients on (to stop the clock starting), and transferring patients from A&E to wards set up alongside them - often known as medical assessment units or clinical decision units (so the clock stops).

While the statistics will say only a very few patients wait for over four hours, the reality - as many testify - is somewhat different, whether the target is hit or missed.

Uncomfortable waits

But what really matters here is whether waiting longer harms patients.

There are always exceptions, but most people would accept that the NHS is good at prioritising the most ill patients.

Therefore those waiting longest will tend to be the patients who are most able to cope with delays.

However, that does not mean that for those individuals there may be some very uncomfortable waits.

That is particularly true for the busiest hospitals.

The units that are most likely to miss the targets and the ones that can least afford too. They tend to be the biggest and busiest hospitals where the sickest patients are taken.

These major units are known as type 1. When you break down those figures to weekly data you can see that overall the target was not hit at all from September to May.

That is a remarkable situation in the modern NHS, as Patients Association chief executive Katherine Murphy acknowledges.

She believes the situation is "reaching crisis point".

But a delve deeper into the figures makes even more worrying reading.

When the figures are broken down by individual hospital there have been weeks where approaching half of patients have waited longer than four hours in some places.

In those situations even with doctors prioritising the sickest patients it gets extremely difficult to make sure the delays do not adversely affect some.

Nick Triggle Article written by Nick Triggle Nick Triggle Health correspondent

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  • rate this

    Comment number 176.

    What targets?

    Resource-spread to match need?
    Resource-levels for efficient triage & back-up?
    Management responsive to accounts of need?
    Exchequer able to call on tax-payer?
    Tax-payer able to trust?
    All 'in it together'?

    Sounds OK? To be expected in a democracy?

    Instead, care deficit from democratic deficit
    Non-representative rule, all 'competing'
    Doctors & nurses priced out of employment

  • rate this

    Comment number 175.

    Re 173--no thx, I dont want to use a Social Network Site, I'm content to post on this site You lot just can't stop "knowing what is best" and telling folk what to do, can you? Folk like you who John_Hendon has been talking about so harrowingly.Why do more patients die at weekends?Could it be that most "professionals" are on the golf-course , SIR ? And, as you dont play golf, perhaps you twitter !!

  • Comment number 174.

    This comment was removed because the moderators found it broke the house rules. Explain.

  • rate this

    Comment number 173.


    I speak from a professional's point of view, sir.

    Clearly your rhetoric lets you down and I do not play golf !

    However I do respect your opinion since you are more than entitled to it..

    As are all members of this site.

    Maybe you should try a Social Network site to pen your barbed derision of others !

  • rate this

    Comment number 172.

    Poor *implementation* of targets is counter productive.
    I know a call centre were staff were targeted on "time to deal with call" - measured automatically - data every hour.
    So if the call sounds difficult? Accidentally cut it and let them ring in again - bit of luck someone else gets the call.
    Those on non-peak hour shifts had better averages.
    Think! Can I subvert this target? Yes? Redesign it!

  • rate this

    Comment number 171.

    Re 170--havent you heard a word John-Hendon has being saying, wally ???
    The "professionals" you're waxing lyrical about are the cause of most of the strife !!! And without ANY targets , we'd soon see the "professionals" saying
    "oh, we don't need to race to deal with an emergency in 4 hours; we can finish our game of golf and make them wait 10 hours". I can't believe posters like you !!!!!!

  • rate this

    Comment number 170.

    When will anyone realise that targets are counter productive.

    Introduce any target and that becomes the focus of staff rather than the care.

    Allow professionals to be just that and scrap targets. You will see waiting times fall and care improve.

    Nothing is achieved from behind a desk. Targets are the problem, not the solution !

  • rate this

    Comment number 169.

    164.BTF "bean counter issue!

    The Medical Director said that he spent 1% on systems but a business of his size (1000 bed hospital) would reckon to spend 4%-5%.

    So there is a bean counter issue - quite apart from having almost no ward clerks to collate, keep up-to-date and summarise a care plan.

    If they had systems - it would save money & provide better outcomes.

    AND my mum would be alive today

  • rate this

    Comment number 168.


    The systems issue doubled the length of my mum's stay and also ended her life. Cost an extra 15K & took her life.

    I have already appeared before the Coroner and 'won' an inquest - the hospital has to produce the full notes - their are also inconsistencies in the autopsy.

    A full, well argued, 'consent' application is before the DPP.

    If we don't stop these people they will do it to others.

  • rate this

    Comment number 167.

    164. Billythefirst "purely a clinical organisational...issue"

    I know what their systems did to my mum. The provision of care was haphazard at times in accordance with a care plan, at times not.

    I met with the Clinical Director for 2.5 hours in a formal minuted meeting and outlined my concerns. He told me that their system are so bad they don't know if patients are in-patients or out-patients!

  • rate this

    Comment number 166.


    The very worst.

    Being confident they can manage a patient's hearing aids - yet on over 20 occasions in 10 weeks putting hearing aids in, but failing to switch them on. This has an appalling effect on patients - yet the staff don't care or bother to check. They did this on my mum's last day and sent her to theatre for the 4th time - I know they did as I took the aids out of her corpse.

  • rate this

    Comment number 165.

    161--deepest sympathy; good luck with your efforts with the DPP, but you must know how the cards are stacked against you by a rotten and vile system.What is happening in our A&Es is a public scandal that MUST be dealt with NOW. AND I remain firm in my belief that we must stand up to the politically-correct brigade and deal with immigrants who have been the main cause of our pop increase to 60+m !!

  • rate this

    Comment number 164.

    So, purely a clinical organisational rather than "bean counter" issue ?

  • rate this

    Comment number 163.


    Staff are LOUD CONFIDENT & WRONG. They don't know what is going on & function without reference to other staff's plans.

    eg Phoning patient at home to come in for a scan when they are an in-patient. Trying a procedure - finding the patient does not 'tolerate' it and yet trying it again! Inability to manage casts resulting in straight bones becoming bent in inpatients & so need an op!

  • rate this

    Comment number 162.

    160.BTF "what do you see as the way forward"

    Fix the internal information systems urgently. Staff do medically sensible things but without reference to what other things are happening to the patient as the 'care plan' is essentially invisible.

    They topped my mum by giving 4 anaesthetics in 3 weeks after botching an operation that should not have been needed if they had cared for her properly!

  • rate this

    Comment number 161.

    156.A R "I never see Queue Busting"

    Try our local London hospitals - it is a regular occurrence that the person in change of A&E will come out to the waiting room to beg patients to go away or put up with 8 hour waits.

    I am waiting on an Inquest re the destruction of my mum and want to see the hospital management changed under the Corporate Manslaughter and Homicide Act 2007 if the DPP allows.

  • rate this

    Comment number 160.

    John, you've obviously been on the wrong end of some very poor service - what do you see as the way forward - assuming you're not convinced that hiring American consultants for £3billion is a cracking idea?

    John M - You are seeking to lay the blame for everything on immigrants - that's a dangerous path.

  • rate this

    Comment number 159.

    Re 155-if you really believe that BS about the waiting disgraces being caused by drunks, you must be in a worldthathasgoneinsane ! And insurance companies most definitely DO pay for ALL cancer treatment ! Do you live in UK, ever looked at a private health policy? Would you class as "obnoxious racist" anyone who asks "if ure a Brit and want our NHS, why do you support a foreign team from Pakistan"?

  • rate this

    Comment number 158.

    "When will the English stop being obnoxious racist & abusing the NHS then it WILL work properly".

    The English might be abusing it - but at least the majority of them paid into it.

    We all forgot it's just the English who get blind drunk and attend A&E - I mean the Scots, Welsh and Irish never do that do they?

    If you're going to post, post sense - not nonsense.

  • rate this

    Comment number 157.

    155 "stop...abusing the NHS"

    No need the NHS is the worst self abuser - far worse than the people.

    see 154

    Their treatment failings of basic care cost £20K and took the life of my mum. Their systems are not fit for purpose. They don't even know if patients and in or out! The dire hospital concerned hasn't even cleaned its windows above the 3rd floor (it has 10) since 1970. Basic failures.


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