Four-hour target in emergency departments

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A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. 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. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, and admitted or discharged in under four hours.[1] 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.[2] Trusts which failed to meet the target could be fined. In July 2016 NHS trusts were set new "performance improvement trajectories". For 47 of the 140 trusts with “type one” major A&E facilities this meant a target of less than 95% waiting under 4 hours.[3] In January 2017 Jeremy Hunt announced that the target would in future only apply to "urgent health problems".[4]


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.


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".[5]

48% of departments said they did not meet the target for the period ending 31 December 2004.[6] 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.[7]

The 4-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labeling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[8]

Although the four-hour target helped to bring down waiting times when it was first introduced, since September 2012 hospitals in England struggled to stick to it, prompting suggestions that A&E departments may be reaching a limit in terms of what can be achieved within the available resources.[9] Interestingly, the announcement of the reduction of the target from 98% to 95% was immediately followed by a reduction in attainment to the lower level.[10]

By December 2014, the number of patients being treated within four hours had fallen to 91.8%.[11]

From December 2015 the 95% target over England as a whole was missed every month. From October 2016 to December 2016 only 4 out of 139 hospitals with major type 1 A&E departments met the target.[12]

Missing the target[edit]

According to the BMA[6] 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.[13]


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.[5]


  1. ^ The Four Hour Target in Accident and Emergency
  2. ^
  3. ^ "Third of providers will still miss A&E target in March 2017". Health Service Journal. 21 July 2016. Retrieved 19 March 2017. 
  4. ^ "Jeremy Hunt ditches four-hour target as A&E crisis deepens". Guardian. 9 January 2017. Retrieved 19 March 2017. 
  5. ^ a b BBC NEWS | Health | Target 'putting A&E care at risk'
  6. ^ a b BMA - BMA survey of accident and emergency waiting times, March 2005
  7. ^ BBC NEWS | Health | A&E success 'not sustainable'
  8. ^ Mayhew, Les; Smith, David (December 2006). Using queuing theory to analyse completion times in accident and emergency departments in the light of the Government 4-hour target. Cass Business School. pp. 2, 34. ISBN 978-1-905752-06-5. Retrieved 2008-05-20. 
  9. ^ Blunt, Ian. "Why are people waiting longer in A&E?". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 2 February 2015. 
  10. ^ Woodcock, Thomas; Poots, Alan J; Bell, Derek (March 2013). "The impact of changing the 4 h emergency access standard on patient waiting times in emergency departments in England". Emergency Medicine Journal. 30 (3): e22–e22. doi:10.1136/emermed-2012-201175. 
  11. ^ "Indicator: A&E waiting times". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015. 
  12. ^ "What's going on in A&E? The key questions answered". King's Fund. 6 March 2017. Retrieved 19 March 2017. 
  13. ^ Blunt, Ian. "Focus on: A&E attendances". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.