Month: January 2017

Is removing the four hour target simply a stupid idea or is it something much more sinister?

So Jeremy Hunt has announced that he will get rid of the four hour emergency department maximum waiting target for the less serious cases (minors) as his only response the the looming NHS crisis. I spent 5 years as a medical director running emergency services for a large NHS trust so I know something about how it all works.

I believe that removing the four hour target for minors is a very bad idea. It will not help the emergency crisis and will cause permanent damage to the integrity of the NHS.

Let me explain.

The essence of the current “humanitarian” crisis is that thousands of patients get stuck on trolleys in emergency department corridors because there are no beds in the hospital to admit them. They suffer appalling indignity and discomfort while receiving second rate care. Ambulance crews cannot offload their patients so they become stuck in hospital car parks and unable to respond to new emergencies. Life gets very dangerous in hospitals and in the community, patients suffer and some die.

The root cause of the problem is lack of hospital beds. The mathematics is very simple. If you multiply the number of patients admitted to hospital by the length of time they stay there and it adds up to more than the number of bed that are available each day there is a problem. You can only fix it by admitting fewer people, increasing the number of beds or reducing the time each stays in hospital.


For many years the number of emergency admissions has been increasing as UK population increases and gets older (on average). Bed numbers have been falling as a result of government policy. We have managed to keep things going by reducing the average amount of time patients stay in hospital but I believe we have now reached the limit of what is possible with early discharge.

It was all bound to fall apart at some point. The trigger for the current crisis was a drastic cut in social services, which made it difficult to discharge frail elderly patients and pushed the whole system over the edge.

So why does removing the four hour target for minor illnesses not help?

Removing the four hour target for minor cases does not affect the number of very sick patients who reach the hospital needing admission, the number of beds available in hospitals or the length of stay for admitted patients, so it cannot possible help flow of patients out of the emergency departments. Patients on trolleys will still fill the corridors and ambulances will still fill the car parks.

But surely it will reduce the numbers of people attending emergency departments. Won’t that help?

If waiting times for the treatment of minor cases go up substantially it may prevent some people attending the emergency departments. They may choose to see their GP or local pharmacist or even not to seek medical advice at all. Waiting times would have to go up quite a lot to make much difference though.

But let’s assume then that waiting times do go up significantly and large numbers of patients stop going to Emergency Departments. This will put additional pressure on GP services, which are already at breaking point. GPs will have to see the emergency patients ahead of their routine work and the treatment of patients with chronic disease will suffer. Ironically less proactive care for elderly patients with multiple illnesses could lead to an increase in acute problems requiring their admission to hospital – and these are the very patients that we struggle to discharge.

Some patients with the early stages of a serious illness may be discouraged from seeking help. It is then much more work sorting them out when they eventually present to hospital in a more advanced stage of their disease.

The pressure that the staff feels at any one time is strongly related to the number of patients in the department. It is very stressful to be surrounded by a sea of patients waiting for treatment. Reducing the number of attendances by increasing the waiting time will not help this. If half as many people spend twice as long in the department you have exactly the same number of people to manage.

Getting rid of the target for just the minor cases will not help the performance figures either. Minors can often be treated and discharged quite quickly. It is the major patients on trolleys with no beds to go to that breach the target.

And then there is the issue of how to work out who is minor and who is major. I don’t think anyone knows how this proposed change could be implemented.

So on the face of it getting rid of the four hour target for minor cases seems a stupid idea. It will not help the NHS crisis but it will definitely put even more pressure on primary care and not only minor cases but also patients with chronic diseases will suffer. Any of us who are unfortunate enough to suffer a minor illness or accident will certainly have a poorer experience and maybe a poorer outcome.

But is it really so stupid?

It is difficult to believe that Jeremy Hunt, or at the least the people who are advising him, have such little understanding of how things work that they think abolishing the four hour target will help anything.

His action makes much more sense if you look at the effects from the point of view of someone who is ideologically opposed to the principle of the NHS and wants to see it replaced by the private sector.

At first sight he has made a concession that to the uninformed looks as though it might be helpful, so a political win there.

But at a stroke he has removed access for millions of people with minor illness and many chronic diseases to large parts of the NHS. They will go untreated or have to treat themselves. If he goes through with this he will have in effect permanently shut down a big chunk of the service.

Many will decide to go directly to the private sector. Mark my words – we will see a big increase in private emergency services over the next few years.


So perhaps it is not stupid after all. Perhaps it is something much more sinister.

Perhaps it is part of the plan……