Four Hours in A&E

I was driving home last night when I heard on the Radio 4 evening news that one of the top stories was a failure of emergency departments in England over the last week to meet the fabled “four hour target”.

The four hour target, which was introduced by the Department of Health in 2003, states that 95% of people attending emergency departments in the UK should be seen within four hours.

Or that’s what I hear every time there’s a news item relating to this target, so let’s clear up a couple of things.

And the first thing is that the four hour target states that 95% of people attending emergency departments should be triaged and seen and treated and moved out of the department within four hours.

I’m not quibbling the rights or wrongs of the target; we could go round and round on that forever. It’s an arbitrary number. It’s been the same arbitrary number for eleven years. That allows us to measure and compare and I suppose gives part of the impetus to improve performance. It has as much value as any other number that might have been chosen, which is to say that it has enormous statistical value and absolutely no moral value.

The target is what it is, but if we’re going to let the media take the NHS to the cleaners every December for a target that it’s failing to meet then I think they should be obliged to talk about that target as it is.

Even with those parameters, the four hour target was achieved for 91.8% of people attending emergency departments in England in the first week of December.

And that figure says something, but it doesn’t say that 8.2% of people attending English emergency departments last week were still in the waiting room at the four hour mark.

We don’t have any December figures for emergency departments in Scotland yet, but the media presume that they will be comparable with England. Last weekend, I was the receiving medic for an inner city Scottish hospital. I spent the first weekend of December trapped in ED (and I do mean trapped — I ate only because my FY1 delivered lunch and caffeine to me, which probably qualifies as abuse of one’s juniors on my part). I cut through the waiting room a lot. That less than 10% of patients were in the department for longer than four hours is fairly remarkable to me.

So far as I can tell, the patients who are well enough to be discharged home straight from ED are not the ones for whom the target falls down (although it isn’t difficult for me to envision a situation in which that process as a whole could take longer than four hours). The target falls down for the patients who are seen and, having had their treatment started, need to be admitted to the hospital.

There is a bed crisis in hospitals in the UK. I don’t know if you’ve noticed. It hasn’t been caused by doctors or nurses or AHPs, who consistently work their socks off and then some. From what I’ve witnessed, it is for the most part being caused by inappropriate attendance at ED less than politicians would like us to believe. It is being exacerbated by those same politicians, who bafflingly seem to think that closing hospitals and reducing the number of available beds is the way to fix it.

(Spoiler: It’s not.)

If a person needs to come into one of those beds, they will be found one.

If the specialty to which they need to come does not have a bed available right now, two things will happen.

First, we will come to you.

You’re having an asthma attack? We’re not going to withhold oxygen and nebulisers until you get to the respiratory ward. You have a raging infection? The cupboards in ED have antibiotics too.

Second, we will keep you in a place of safety.

And it breaches the four hours and governments don’t like it and patients don’t like it and the media sort of love it, but emergency departments are a place of safety. And are better for patient safety than transferring unstable patients to a non-ED bed across a city, or giving a less sick patient a higher priority for a bed than a sicker one merely because of waiting time, or discharging patients inappropriately. And the days when those things are true are more frequent than anyone who works for the NHS would like them to be, so when they are true we do the very best we can with what we’ve got and we go home at the end of the day knowing that we worked for the good of our patients and not for obedience to a government target.



  1. Having been admitted twice to A&E in one year, in January in Aberystwyth and only last month in Inverness, I can testify to the fact that A&E truly does feel like a place of safety after a long and painful ambulance ride to get there. I honestly don’t know how long I waited each time to be admitted for emergency surgery, but at no time did I feel forgotten or neglected. Inverness in particular was obviously busy, but I was treated with care and true professionalism. As far as I’m concerned, the NHS is one of this country’s greatest assets and to be supported, not dismantled.

  2. Dear Beth, I’m not a medic, but I enjoy and value your blogs about life as a doctor. I have enormous respect for the NHS, which is the implementation of a key Christian idea. In my own experience (I was treated for cancer a few years ago) I met nothing but kindness and understanding. I dread a move to the American pattern, where the chief motivation seems to make as much money as possible out of the patients or their insurers. Keep up writing your blogs (if you have time!). Best wishes,


  3. Everyone will speak as they find. I have had to have my husband taken to A&E on a number of occasions. Some times he’s admitted sometimes a few hours later I am able to take him home. I don’t know how long this takes what matters is that we r treated with respect and and there is always someone on hand to help. Doctors and nurses are hard pressed and work hard sometimes a little humour with them or understanding their problems goes a long way. I swear by the NHS and we should be thankful we have it!! I know I am.

  4. Reblogged this on FAT MAN ON A BIKE and commented:
    I’ve never reblogged something before, but this says many things better than I have done. If I can edit the post after reblogging, I’ll put some photos in it for you. I know you like photos.

  5. Dear Beth, Our daughter is a Staff Nurse in A & E Dept, Swindon. She works very hard and is very conscientious and caring. They are well aware of the 4 hour target, set by people who have never worked in an A & E Dept, most likely never seen one. Sadly, the big problem is the “Time Wasters” who go to A & E. Stop the time wasters and iam sure all A & E depts will meet their targets. It is a pity that the Department of Health does nor concentrate on this issue, or are they frightened of the “PC” and “human rights” brigade. The NHS needs our support, cut down on the paper work and “non” medical staff in Hospitals. A very proud Father. xx

    • I consider myself to be both politically correct and pro-human rights, and I don’t believe that either of those qualities are vices, so I shall tread carefully.

      I think it depends on what you consider to be a time waster. I think that people who genuinely ought not to be in an emergency department are fewer than politicians would have us believe — which is not to say that they don’t exist, of course; if you have time to get into an in-depth argument with reception about what day of the week would be better for you to come back and be seen more quickly, you are not an emergency. It is statistically very well documented that the crisis that has arisen this month is because of an increase in admissions from A&E, not attendances at A&E. It doesn’t matter how many so-called time-wasters turn up at A&E, the only people who are going to be admitted are the ones who are sick enough to need to be there. It’s that that creates a bed crisis, and that has a direct and massive impact on the ability of A&E to get patients out of the department and into wards. If the Department of Health is really stuck to getting everyone out of A&E within four hours, they’re not going to achieve it by anything other than creating hospitals with more beds (and stopping cutting the ones we’ve got).

  6. I think the NHS is fantastic!! But only if you are ill….trouble I I’ve seen people pushing wnd bullying because their son or wife etc has an I jury…wanting to be put in front of a heart attack patient and on and on…I’ve seen nurses being expected to give a drink to a patient while the family eere sitting by the bed..even though she was looking after the whole 10 patients in the ward and was herself obviously pregnant!!
    Becsuse I have a thyroid problem and had iodine treatment etc…for years now I have not had to pay for operations; medication snd countlesd regular blood tests…name one other country where you can get this whether you pay or not….name one? The NHS is brilliant!! The closing of hospitals us sad.

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