The NHS Plan1 introduced a series of targets for England in 2000, including that patients should spend no longer than 4 h in the emergency department from arrival to discharge or transfer to a ward. It has been demonstrated that focussed targets can help drive improvement.2 But Bevan and Hood3 highlighted the ‘element of terror’ required by targets, combined with an assumption that problems of measurement and gaming do not matter. Goodhart4 stated ‘Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes’. The 4 h emergency care access target in England has at times demonstrated all these features. Without it the patients in emergency departments in England could still be waiting in corridors and have the well-described increased adverse events5 and increased mortality6 related to overcrowding, but equally we have also seen examples of over-focus on the target. Harndern7 describes the 4 h target as an example of a destructive goal pursuit and he stresses the need for multiple goals, for all domains of quality to be addressed in these, and for a focus on effective team working and team learning. The target has on occasions resulted in perverse actions aimed at solely achieving that target and forgetting the reason it was created—to reduce unacceptable delays that can result in worse outcomes and increased likelihood of unnecessary admission8 as well as being a common source of decreased patient satisfaction.9 Using a single headline indicator for one clinical …