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Royal College of Emergency Medicine


7-9 Bream’s Buildings London EC4A 1DT

Emergency Medicine Briefing: Making the Case for the FourHour Standard

Please find below the Royal College of Emergency Medicine's Brefing: Making the Case for the Four Hour Standard.

Key messages

• In England the Four-Hour Standard was met in all types of Emergency Departments from 2004-05 until 2013-14. Annual performance remained above 90% in Type 1 EDs from 2004-05 to 2014-15.

• The Four-Hour Standard was introduced to the NHS in England in 2004 to combat crowding in EDs. Since its introduction there is no doubt that waiting times have been reduced.
• Evidence for the efficacy of time-based targets is limited in the UK but more extensive overseas. A single centre UK study showed that improvements in performance against the standard were associated with reductions in mortality.
 • Several Australian studies have shown reduced mortality associated with introducing a timebased target.
• Since 2015 NHS Emergency Departments in England have failed to meet the standard. 
• This is a result of increasingly elderly and complex case demographics, restrictions on social care services, inadequate staffing levels and insufficient acute bed provision.  
• We are often told that the reason that the NHS is unable to open more beds for patients is because of a shortage of clinical and nursing staff.  
• This is only partly true because NHS data shows that in successive years, the number of medical staff in NHS hospitals has gone up while the number of available beds gone down.  
• Rather, this is also because as Trusts’ finances have worsened they have come under pressure to close beds to save money. Bed occupancy rates are now routinely over 90%.  
• The RCEM has argued that we should return to bed occupancy rates of 85% because this supports patient safety and Four-Hour Standard performance. The last quarter in which performance reached 95% at Type 1 Emergency Departments bed occupancy in the NHS in England stood at 85% 
• Crowded Emergency Departments have poor working conditions, increased staff burnout and reduced retention. This is known to adversely affect patient care.
• Putting the necessary investment in place to maintain the Four-Hour Standard will help to minimise the costs to NHS providers associated with litigation.

• The present target has been successful in improving the resources that are available to provide emergency care for patients. 

• If the Four-Hour Standard were to be replaced, we would need to explain why this would not mean a deterioration in care for patients, because politicians and managers had less incentive to prioritise the resources available to urgent and emergency care.

Read the full briefing here: Making the case for the four-hour standard (2018)

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