By E. Moran, Health Systems Analyst
Somewhere between the triage desk and the curtained cubicles of Australia’s emergency departments, there’s a ticking clock that shapes everything – not to save lives, but to meet targets.
For decades now, emergency departments have operated under a funding model that rewards time-based performance metrics. The faster you can get a patient “processed” – offloaded from an ambulance, assessed, and either admitted or discharged – the more funding flows. The clock stops, and the spreadsheet glows green. But behind those data points lies a system that has quietly been failing.
The genesis of this model traces back to the late 1990s and early 2000s, following similar shifts in the UK’s NHS and later mirrored in Australia. Faced with public concern about “hospital ramping” and overcrowded emergency rooms, policymakers began tying funding and reputational outcomes to metrics like the “four-hour rule.” This rule, originally intended to drive efficiency, mandated that a certain percentage of emergency department presentations be completed (i.e., discharged or admitted) within a four-hour window.
But in practice, the target quickly overtook the purpose. Time became the priority – not care.
The promise was simple: improve efficiency, reduce wait times, and boost public satisfaction. The reality? Hospitals started “stopping the clock” in creative ways: moving patients from EDs into temporary wards, observation rooms, even hallways – not because care was complete, but because the metric had to be met.
Funding tied to this movement became a perverse incentive. If a hospital wanted to survive financially, patients had to move – ready or not. The result is a system that does not reward quality of care, diagnostic accuracy, or long-term recovery – just throughput.
It’s a shell game. The patient doesn’t get faster care. They just get moved from one under-resourced part of the hospital to another.
This model assumes a world of adequate staffing and sufficient inpatient beds. In reality, neither exists. Nurses are burned out, ED doctors are running at unsustainable ratios, and hospitals regularly operate above capacity. You can’t reduce waiting times by fiat when the bottlenecks – upstream and downstream – haven’t been addressed.
The funding that comes from “hitting targets” is often already committed. Hospitals rely on it just to cover basic operations. It’s not a bonus for performance – it’s a lifeline. And so, the machine keeps moving patients, not because it helps them, but because the budget demands it.
A truly modern system would flip the model: fund based on outcomes. Measure what matters – survival, recovery, misdiagnosis rates, re-presentation within 7 days, patient satisfaction, and staff retention. We know this kind of investment saves money in the long run. A timely and accurate diagnosis is cheaper than a second visit, a preventable complication, or a readmission.
Funding should flow to services that reduce future hospital load: primary care, community mental health, aged care beds, post-acute rehab. These are the buffers that prevent people entering the emergency system in the first place. Starving them creates demand at the worst possible point – the front door of the ED – where costs are highest and risks are greatest.
No more stopwatches. No more perverse incentives. No more celebrating the “transfer” of a patient from an overcrowded emergency department to an understaffed short-stay unit as a success story.
We need a health system that values what happens to the patient – not just where the patient is.
As long as the clock is king, hospitals will be forced to choose between gaming the system or going under. It’s time to stop measuring what’s easy and start funding what matters.
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One gets the whiff of Frederick Taylor's Scientific Management for assembly lines eg. Henry Ford, or worse, eugenics.
It's not just supposed efficiencies or economies, let alone effectiveness and product quality, but controlling employees like precluding unions in a workplace.