• Emergency Service
• hospital
• Organisation and administration
• Quality indicators
• healthcare
• clinical assessment
• effectiveness
• emergency care systems
• management
• emergency department management
• research
• operational

The 4-h target was conceived in the excitement of a New Labour victory, and its anticipated arrival was announced in the NHS plan in 2000.1 After a 4-year gestation, it hit the ground running in England in 2004.

The target stipulated that nobody would have to wait more than four-hours in an ‘Accident and Emergency’ department. The standard was soon modified to 98%, to allow for ‘clinical exceptions’. As with any new arrival, the target went on to dominate the lives of emergency physicians in the UK for the next 6 years.

The target had face validity. Long waits in emergency departments (EDs) were common and nobody wanted to see them. Despite this, initial thoughts in the specialty were that the target was not achievable. It soon became apparent, however, that we had underestimated the political pressure that would be brought to bear by a government determined to drive its reforms through, and to follow a top-down style of change management. Adopting strategies used by parents the world over, a combination of persuasion (emergency care collaboratives), incentives (cash), direct pressure (‘you will do as I say’) and naughty corners (turnaround teams) was employed.

Demand management did not deliver the promised reductions in workload.2 A combination of NHS Direct, minor injuries units, walk-in-centres, emergency care practitioners and so on, served to make the healthcare system more complex, with questionable benefit, while at …