Four-hour target in emergency departments

A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours. The target was revised by the Department of Health to 95% in June 2010.^[1]

Objective

The UK Labour government had identified a requirement to promote improvements in A&E departments, which had suffered underfunding for a number of years. The target, accompanied by extra financial support, was a key plan to achieve the improvements.

Results

Tony Blair felt the targets had been successful in achieving their aim. "We feel, and maybe we are wrong, that one way we've managed to do that promote improvements in A&E is by setting a clear target".^[2]

48% of departments said they did not meet the target for the period ending 31 December 2004.^[3] Government figures show that in 2005-06, 98.2% of patients were seen, diagnosed and treated within four hours of their arrival at A&E, the first full financial year in which this has happened.^[4]

By December 2014, the number of patients being treated within four hours had fallen to 91.8%.^[5]

Missing the target

According to the BMA^[3] the main reasons for not reaching this target are:

• Not enough inpatient beds
• Delayed discharges
• Delay in accessing specialist opinion
• Not enough nurses
• Not enough middle grade doctors
• Department too small
• Delay in accessing diagnostic services

In 2014, research conducted by QualityWatch, a joint programme from the Nuffield Trust and the Health Foundation, tracked 41 million visits to A&E departments in England in order to better understand the pressures leading to increased waiting times and breaches of the four-hour target. Researchers identified a rise in older patients and related increase in long-term conditions as key factors, alongside extremes of temperature (in both summer and winter) and crowding at peak times. They noted that the majority of pressure was falling on major A&E units, and proposed that rising demand as a result of ageing and population growth may be pushing already stretched emergency departments beyond maximum capacity.^[6]

Exceptions

The original target was set at 100%, but lowered to reflect clinical concerns that there will always be patients who need to spend slightly longer in A&E, under observation.^[7]

The target was further moved to 95% of patients within four hours in 2010 as a result of the coalition's claims that 98% was not clinically justified.^[8]

Pressure

Even though exceptions are allowed to the targets, concerns have been raised that the target has put pressure on A&E staff to compromise patient care. A significant proportion (90%) of A&E consultants welcomed the four hour target in a study but felt that 98% was too high a target.^[2]

References