Comment

The four-hour target: what’s the point?

Dr Adrian Boyle, consultant emergency physician at Addenbrooke’s Hospital, considers the case for maintaining the four-hour access standard in emergency departments, despite its imperfections.

Few performance measures in the NHS generate as much heat and debate as the four-hour access standard. Currently very few type 1 emergency departments are able to achieve this performance measure, and there have been suggestions that the target should be revised or scrapped. It is worth considering the history and effect of the target. 

Timeliness of care is recognised as a key component of high-quality healthcare. Patients attending emergency departments repeatedly value short waiting times. 

In 2000, the English government was coming under significant pressure to improve care in emergency departments, with negative articles regularly appearing in the press. At the time it planned to limit the time patients spent in emergency departments. But in 2004, it introduced a rule that 98% of patients would spend no longer than four hours in an emergency department; other devolved nations in the British Isles followed shortly afterwards. Failing to comply with this rule would attract significant financial and administrative penalties. This was later relaxed to 95% in 2010, but remained at 98% in Scotland. 

The four-hour access standard is an intuitive, pragmatic and simple process measure that holds acute trust boards to account to improve emergency care. It provides powerful incentives for NHS managers to improve patient care in emergency departments. Recently, it has become apparent that the standard is a useful indicator of how the whole urgent care system – from NHS 111 call, primary care contact, ambulance response, emergency admission and discharge to social care – performs. 

Criticisms of the standard 

However, it is less clear what the four-hour access standard does to improve care. Pressure to achieve the standard was cited as a contributing factor to the poor standards of care in Stafford Hospital. Critics of the target point out that it is merely a process measure. 

There have been further criticisms of the standard, which suggest it leads to ‘gaming’ and ‘cheating’. Others say it impairs training and recruitment, reduces professional satisfaction and creates an adversarial culture between the emergency department and other inpatient specialties. Further criticisms are that the data is unreliable. It is also unfairly used to compare hospitals with very different case mixes. For example a major trauma centre, with on-site stroke thrombolysis and vascular surgery, has a more complex and time-consuming case mix than a paediatric emergency department, and comparing these hospitals is not sensible. 

The standard can be useful to garner organisational support both from within the hospital and from commissioners. The four-hour standard encourages hospitals to increase the number of senior emergency physicians and emergency nurse practitioners. However, the standard creates significant pressure on the nursing staff, who are made to feel responsible for breaches and that they should spend less time with patients. Sicker and more complex patients benefit less from the standard than less ill patients. 

There is some evidence that achieving the four-hour standard is associated with reduced inpatient mortality among emergency admissions in Britain. The Australian picture is more positive, with the introduction of the National Emergency Access Target being associated with a substantial decrease in mortality from 1.12% to 0.98%. Though this value sounds small, it should be remembered that small changes in a high-volume system are important. 

The number of patients seen and discharged within four hours has improved considerably. Before 2001, 23% of patients spent longer than four hours in an emergency department. Flow dynamics are dramatically altered, with a surge of activity of patients leaving in the last 20 minutes of a four-hour stay. Somewhat counter-intuitively, research suggests that the standard does not increase admissions to hospital or return visits within one week.

Removing the standard takes away an incentive for trusts 

Any discussion of the imperfect four-hour access standard should consider alternatives. The UK government briefly considered removing the standard, but found that other potential key performance indicators could not be reliably collected.  

Removing the target completely would remove an incentive for trusts to improve care in emergency departments. International evidence shows that hospitals prioritise income-generating elective work over poorly-funded emergency care; this contributes to emergency department crowding. The Royal College of Emergency Medicine (RCEM) has repeatedly identified emergency department crowding and exit block as serious public health problems and estimates that 3,000 people die a year as a consequence. 

Other care standards exist for indicator conditions e.g. to antibiotics for pneumonia or time to a cardiac catheter laboratory for patients with acute myocardial infarction. These measures create a halo effect, where the indicator condition receives disproportionate resources at the expense of other patients. The RCEM is of the opinion that any emergency department standard should promote quality across all patient groups, including the large number of those with undifferentiated presentations. 

Standards must promote improvements across all domains of quality, not just timeliness of care, and should also be applied across all points of urgent and emergency access – not just the emergency department. The council of the RCEM debated and voted unanimously to retain and support the four-hour standard in March 2014.  

The four-hour access standard has become part of the fabric of UK hospital care for the last decade. It is probably beneficial to patients, but the greatest advantage does not accrue to those in greatest need. Substantial costs have been incurred to deliver the target and pressures on staff have become extreme at times. 

Despite all the imperfections of the four-hour access standard, there is no credible alternative and, now perhaps more than ever, we need it to show the current difficulties in our emergency departments.

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