06.03.15
A&E waiting times targets ‘distort priorities and could undermine care’
The emphasis on A&E waiting times targets to admit or discharge 95% of patients within four hours is distorting priorities and could be undermining care, the Nuffield Trust has warned.
The think tank says the way the system currently reacts to performance fluxuations against the four-hour target can distort behaviours inside hospitals in ways that are not in the interests of patients or staff. They say that too much of staff time is spent reporting upwards to commissioners and regulators, with potentially detrimental impacts on the quality of care.
A new briefing released today argues that new approaches to performance management, with other measures given equal status to the four-hour target, should be adopted.
Nigel Edwards, chief executive of the Nuffield Trust and one of the authors, said: “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.”
The briefing argues that a broader and more long term view of A&E performance is needed. Officials should give less weight to the four-hour target, and start looking at other indicators such as the number of people leaving A&E without being seen and how long people wait on trolleys after the decision to admit them to hospital.
Overall the four-hour target has not been hit on a weekly basis since September, however when you look at just major A&E departments the figures get even worse, as they have not met the target since 2013.
The figures also show that 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.
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 believe 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.
Edwards added: “The four-hour target has come to loom over every other measure of how well patients with urgent needs are being cared for. Nobody denies that it really matters to people. But there are a lot of other things that matter in emergency healthcare.
“Politicians and regulators need to stop micro-managing this target and should instead examine how to put the four-hour target on an equal footing with other critical indicators like trolley waits or time to treatment. This could be achieved by introducing clustered randomised controlled trials of such indicators in some areas.”
Professor Matthew Cooke, former urgent care tsar at the Department of Health, said that he “wholeheartedly” agreed with the Nuffield Trust that too much focus is on the four-hour target.
“The wider set of indicators I introduced when I was National Clinical Director were aimed to prevent this over focus and create a balanced set of quality measures,” he said.
“But the intense performance management of the four hour target has negated the impact of the balanced set of measures. Concentrating on the whole system and measuring quality across that whole system is, in my opinion, the way forward."
A spokesman for the Royal College of Emergency Medicine said: “The College agrees that the performance of A&Es should not only be judged by the four-hour target – we also need to look at bed occupancy rates, delayed discharges, and the problem of ‘Exit Block’ in departments.
“The College also agrees that primary care practitioners should be given the support necessary to provide high quality urgent-care services, and that the complexity of different services which has been built into the system should be simplified.”
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