Why the four-hour wait target in EDs should stay in place

Hospital emergency departments failed to meet waiting time targets again this year, but patient safety remains a priority

Hospital emergency departments failed to meet waiting time targets again this year, but patient safety remains a priority

Picture: Charles Milligan

Since 2015, emergency departments (EDs) in England have failed to meet the four-hour target for assessing, treating and either admitting, discharging or transferring 95% of patients.   

Performance in England is now the lowest since the target was introduced in 2004. In 2018, on average, one in six ED attendees spent longer than four hours in the department, compared with one in 16 in 2012-13.


people, on average, were admitted to hospital via the emergency department each day in the first eight months of 2018

Source: House of Commons (2018)

Despite this, the Royal College of Emergency Medicine (RCEM) is reiterating calls for the government to retain the four-hour target. In a briefing paper, Emergency Medicine Briefing: Making the Case for the Four-Hour Standard, recently sent to Department of Health and Social Care officials, the college states the target is ‘achievable’ and was met in all types of EDs across the UK for around ten years.

Reducing bed occupancy

Rather than diluting or even axing the standard, the RCEM argues that the focus should instead be on reducing bed occupancy rates – now routinely more than 90% – to 85%. The lower rate is crucial to achieving the four-hour standard, the college says.

Indeed, as the briefing paper points out, the last quarter in which four-hour standard performance reached 95% at type 1 EDs bed occupancy in the NHS in England stood at 85%. Following this, the RCEM wants to see an additional 5,000 hospital beds to return bed occupancy rates to 85%.

RCEM policy research manager and author of the briefing paper Simon Howes says: ‘Insufficient acute bed provision is the main factor hindering compliance with the four-hour standard,’

‘On a basic level, if there are not enough acute hospital beds to put patients in, once a decision to admit has been made, then they will remain in a corridor in the ED. The exit block then causes performance issues with the four-hour standard.’

Dr Howes also points out that while much of the publicity around waiting times is for minor ailments better dealt with at home or via a GP, it is patients with complex conditions who take time to admit who are more likely to cause a time breach.

Timeline of the four-hour emergency department standard

  • 2004 – No one should wait in emergency departments in England for more than four hours, from arrival, to admission, transfer or discharge. Target modified from 100% to 98% of all patients to allow for ‘clinical exceptions’ 
  • 2005 – NHS Wales adopts a 95% target, with a view to achieving it by 2006
  • 2006 – Northern Ireland adopts a 95% target, with a view to achieving it by 2008
  • 2007 – NHS Scotland set a target that 98% of attendees should be admitted, transferred or discharged in four hours
  • 2010 – NHS England revises the four-hour standard from 98% to 95%
  • 2015 – NHS boards in Scotland set the standard at 95%, with boards working towards 98%

Source: Royal College of Emergency Medicine (2018)

The RCEM’s briefing paper lists the benefits that have resulted from the target, including:

  • Reduced waiting times and associated reductions in mortality.
  • Improved staffing.
  • Bed management and access to investigations.
  • The set-up of short stay and ambulatory care units close to EDs.

With the government due to announce its £20 billion spending plan for the NHS in the coming weeks, ED clinicians want improvements protected. And everyone agrees a systems approach is needed.  

‘The lack of inpatient bed capacity in the UK is at a crisis point with occupancy rates running unacceptably high at over 90%’

Matthew Osborne, emergency department charge nurse, Southend University Hospital

Matthew Osborne, charge nurse at Southend University Hospital’s ED says many of the problems faced by EDs centre on exit block caused by the lack of beds.


increase in the number of emergency admissions to hospitals in the past five years

Source: House of Commons (2018)

‘The lack of inpatient bed capacity in the UK is at a crisis point, with occupancy rates running unacceptably high at over 90%.

‘While there are issues in emergency care around doctor and nurse training as well as retention, most of the breaches at my trust end up relating to access and exit block.’

Mr Osborne, who also lectures pre- and post-registration nursing students on acute and critical care at the University of Essex’s School of Health and Social Care, says having a time-based target for EDs is sensible.

Matthew Osborne: ‘Bed occupancy
rates are running high at over 90%’ 

Focus on assessment and stabilisation

‘EDs should be focused on the initial assessment and stabilisation of patients before they are moved on to more definitive care. Having a window of time to do this is reasonable’.

But he adds that, in his experience, the lack of appropriate beds means ED nurses are also commonly delivering resuscitative care, while beds are found.

‘Working in a busy ED with a historic lack of inpatient bed availability, especially with regard to higher dependency care, means a significant number of patients have had a prolonged stay in resus.’

Using cardiopulmonary resuscitation (CPR) as an example, he says: ‘Patients were too sick for a more general ward, while their ceiling of care was not for CPR or an intensive care unit admission.’

Mr Osborne is writing a dissertation on multi-factorial effects on patient mortality in the ED as part of his doctorate. He adds that focusing on the four-hour target alone is flawed, and that monitoring the mean and median wait gives a better indication of how a department is fairing.

‘We should be looking at the whole distribution of waits for different patient types and we should be applying statistical process controls to learn from changes and failures.’

In its briefing paper, the RCEM also points out that as well as bed provision, increasingly old demographics, restrictions on social care services and inadequate staffing levels have added to ED woes.


more hospital emergency department attendances each day than five years ago 

Source: House of Commons (2018)

RCN professional lead for acute and emergency care Anna Crossley agrees that compliance with the target is being hit by various factors. 

High level of nursing vacancies

‘The greatest challenge to the four-hour standard had been issues of bed availability exacerbated by increased delays in transfers of community and social care.

‘These usually occur more frequently in winter, but this summer’s heatwaves have caused a huge increase in admissions. The expected seasonal recovery in four-hour standard performance did not take place. This is almost certainly due to increases in attendances and admissions to record levels.’

‘While this target may seem to put pressure on the system, its introduction has been for patient safety’

Anne Crossley, RCN professional lead for acute and emergency care

She says that until nursing vacancies across the healthcare sector are addressed, hospitals will struggle to meet the target again.

Anne Crossley: ‘The challenge
we are facing is the high level of
nursing vacancies’

‘The challenge we are facing is the high level of nursing vacancies. This puts a huge amount of pressure onto nursing staff, and can make it difficult for providers to achieve the desired effect from improvement programmes.’

But Ms Crossley argues that few nurses would want to see the four-hour standard abandoned.

‘While this target may seem to put pressure on the system, its introduction has been for patient safety and few nurses would want to defer back to a system where patients waited unseen in waiting rooms for hours on end to their detriment.’

Mr Osborne adds: ‘We need to teach first aid and basic healthcare in school so that the next generation can self-care without the need to consult a GP for every sore throat.

‘We need improved access to primary care and district nursing and bed occupancy rates of 85% in acute care. At this point, many of the issues EDs face will start to ease.’

Further information

Tamsin Newton Snow is a health writer

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