Editorial

Long delays to admission in emergency departments cause higher mortality: implications for the 4-hour target

NHS England is planning to abolish the long-standing 4-hour target for waits in emergency departments. The target has been criticised as an arbitrary management target that is unrelated to clinical outcomes, but waits much longer than 4 hours in the emergency department cause a notable increase in mortality for admitted patients, suggesting that the 4-hour target is clinically important and should not be abolished.

Stephen Black1

Author details can be found at the end of this article Correspondence to: Stephen Black; steve.i.black@gmail.com

How to cite this article: Black S. Long delays to admission in emergency departments cause higher mortality: implications for the 4-hour target. Br J Hosp Med. 2022. https://doi.org/10.12968/ hmed.2022.0090

Context One of the key characteristics of the Blair reforms of the NHS in the early 2000s was the introduction of tough targets for elective and emergency department waits – nobody would spend more than 4 hours in the emergency department before discharge or admission and nobody should spend more than 18 weeks waiting for elective treatment. These targets were achieved and public satisfaction with the NHS rose sharply as a result.

But the emergency department 4-hour target was subject to much criticism. Some claimed that a target would distort clinical priorities. Some claimed it was arbitrary and not based on clinical reasoning. Some claimed it was impossible to meet, given how many long waits were occurring in the system.

Despite this, the target was met just a handful of years after it was set, and the NHS continued to meet it for more than half a decade. Hardly anyone attending an emergency department waited longer than 4 hours for treatment or discharge. However, performance has declined consistently since 2011 and is currently at the worst levels ever measured, with the system as a whole struggling to get even 70% of patients dealt with in 4 hours (this was closer to 60% in major emergency departments across England in December 2021 (NHS England, 2021).

One result of the decade-long problems with prompt treatment or admission has been a renewed wave of criticism of the 4-hour target. The week before this editorial was written, health secretary Sajid Javid said that the 4-hour target was ‘the wrong target’ because it distorted clinical decisions (Kituno, 2022). NHS England (2020) has been discussing a set of replacement metrics (including the abolition of the 4-hour target) for several years, although these have not yet been implemented.

Javid is not the first to suggest the abolition of 4 hours as a metric. Andrew Lansley proposed its abolition in 2010 when he became health secretary (Topping and Campbell, 2010), but was eventually talked out of outright abolition and chose to downgrade its importance and relax the standard instead. Significantly, this standard has rarely been met since in major emergency departments. The relevance of 4-hour waits to patient outcomes One of the most common initial criticisms of the target was its lack of relationship to hard clinical outcomes, and this criticism is still frequently raised today. However, a recently published analysis found it does matter clinically, because long waits lead to a significant increase in mortality (Jones et al, 2022). This study is not the first to highlight the possibility that long waits are bad for mortality. A significant study by Guttmann et al (2011) used Canadian data and showed that longer waits were associated with increasing mortality, just in time to demonstrate the problems with the Lansley proposal to abolish the 4-hour target.

Jones et al (2022) took 2 years of data from English emergency departments. These data were not based on a sample; instead, the study used the complete official dataset of all

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British Journal of Hospital Medicine  | March–April 2022  |  https://doi.org/10.12968/hmed.2022.0090