4-hour standards and staffing. Can we square the circle?


It’s been a turbulent and highly unpredictable few weeks in the UK. The Brexit vote to leave the EU, a new Prime Minister and the main opposition Labour party seemingly at war with itself have dominated the headlines. In amongst this we have seen the retention of Jeremy Hunt as Secretary of State for health  amidst a brutal cabinet reshuffle.  I think it’s fair to say that this was not a popular choice for many NHS workers, but perhaps it does mean that we have a degree of predictability and continuity.

Or do we?

Yesterday I gave a talk at our local trainee’s day about the future of emergency medicine. I suggested that financial pressures in the UK may lead to a change in the targets that currently dominate departments and the experience of those working in them. The 4-hour target (standard as it is formally known) requires emergency departments to admit or discharge 95% of patients within 4 hours. We’ve not been meeting it for some time (and in fact some hospitals have more bespoke targets but let’s not get picky here). Have a look at the graph below, it does not read well.

Perhaps this is a time to bury bad news and so it was that we heard about a revision/relaxation of the standards for hospitals already in crisis. Some will welcome this, but beware, those of us who remember a time before targets a very much aware that they have driven substantial investment in emergency services and in particular staff. Not enough I grant you, but it has had a significant influence.

Similarly concerns around safe staffing followed reports into patient safety events at Mid Staffs hospital leading to increases in staffing and the stretching of NHS budgets. Many hospitals recruited extra staff to meet safe levels following internal reviews or external reviews from organisations such as the CQC. A safe hospital is not a cheap hospital, and safety relies on trained, motivated and capable staff to look after our patients and each other. This is especially the case in emergency care where staffing is a large part of the budget.

You don’t need to read the entire Francis report on Mid Staffs, but it has been highly influential. The tweet below from Shaun Lintern (who is well worth following) rather sums up that report, essentially it raised the major concern that financial and admin targets can pervert the delivery of safe and effective care. Clearly we don’t want to repeat this.

The double whammy yesterday was the less well publicised report from NHS Improvement stating that many UK hospitals had over recruited and would thus have their budgets cut as a result. The report lists trusts who have allegedly overspent in line with increases in activity or inflation. The methodology has been questioned and the reaction from trusts has been fierce.  Click on the link in Shaun Lintern’s tweet to read the hospitals named. You may well recognise them. I certainly know many well and I can assure you that they are not awash with staff. Many are in significant difficulties facing the constraints of finance, targets amidst a desire to care for patients and keep them safe.

It is difficult to see how emergency care services will balance the financial requirements announced yesterday together with a need to maintain patient safety and deliver a quality service. It is even more difficult to see who will be blamed when the equation cannot be met. I suspect that the NHS senior management will be happy to devolve that to trusts and departments, but we shall see.

For now, for anyone celebrating the death of the 4-hour target, beware, it’s bound to be replaced by something else and that may be even less palatable.




The views expressed here are mine and do not represent the position of the EMJ or BMJ publishing.

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