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Four hour waiting targets are distorting priorities in A&E

Performance management needs a rethink, says think tank

Jo Carlowe

Friday, 06 March 2015

A&E waiting targets have ‘distorted’ priorities and should be rethought, a major think tank warns today. 

In a briefing aimed at political leaders in the run-up to the General Election, examining the reasons behind England’s A&E crisis, the Trust warns that the emphasis on the ‘totemic target’ of decided on whether to admit patient within for hours has become disproportionate. It argues that a new approach to performance management is needed with other measures given equal status to the four-hour target. 

“England's A&E system is near crisis. With the financial squeeze set to continue, there is no relief in sight if we keep up the current approach. We need to rethink our assumptions as many of the ‘magic bullet’ solutions suggested miss the point. It's not about more people turning up, but about a system with a squeeze on hospital space and staff, which needs to get better at discharging people safely and on time,” says Nigel Edwards, Nuffied Trust chief executive and author of the report. 

The report warns that the four-hour target can distort behaviours inside hospitals in ways that are not in the interests of patients or staff. This, the think tank says, can mean that significant amount of staff time is spent reporting upwards to commissioners and regulators, with potentially detrimental impacts on the quality of care.

The briefing argues that policymakers should instead take a longer-term and broader view of performance in A&E, which may involve relegating the four-hour target to sit alongside a richer set of indicators. These could include the number of people leaving A&E without being seen or how long people wait on trolleys after the decision to admit them to hospital. Such an approach was announced by the then urgent care tsar Matthew Cooke in 2010 but has not been realised.  

‘What’s behind the A&E “crisis”?’ says emergency departments are near ‘breaking point’ and that  major A&Es have not met the four-hour target (that 95% of patients should be admitted to hospital or sent home within four hours of arrival) since 2013; the number of patients waiting on trolleys for over four hours has almost trebled since 2010/11; and the numbers of delayed ambulance handovers have risen by 70% over the same period.

Yet other measures, such as waiting times to treatment and re-attendances within seven days have changed little.

The authors argue that the cause of the pressures has been misunderstood, with too much focus on the 2004 GP contract, NHS 111 and the gradual increase in numbers of people attending emergency departments. They show that long-term trends and immediate causes are often confused, suggesting that the recent problems are driven by an inability to discharge hospital in-patients quickly and safely enough to keep A&E patients flowing through hospitals. 

The Royal College of Emergency Medicine has welcomed the publication from the Nuffield Trust, stating that it agrees that the performance of A&Es should not only be judged by the 4 hour target.

“We also need to look at bed occupancy rates, delayed discharges, and the problem of ‘Exit Block’ in departments,” states the College, adding that it agrees that primary care practitioners should be given the support necessary to provide high quality urgent-care services.

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