A briefing examining the real reasons behind England's A&E ‘crisis’ has warned that the emphasis on the totemic target of deciding on whether to admit patients within four hours has become disproportionate. It argues that new approaches to performance management, with other measures given equal status to the four-hour target, should be adopted.
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.
Nigel Edwards, Nuffield Trust Chief Executive and report author
In the briefing aimed at political leaders as the General Election approaches, the Nuffield Trust think tank says that measuring the performance of A&E departments is essential. But how we react to changes against 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”?’ describes how emergency departments are near "breaking point". It presents data showing that major A&Es have not met the four-hour target (that 95 percent 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 per cent 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.
Nigel Edwards, Chief Executive at the Nuffield Trust, 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. That doesn’t negate the need to for bold strategic re-design to ensure the urgent care system is fit for the long-term.
"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."
Commenting on the briefing, Professor Matthew Cooke, former urgent care tsar said:
"I wholeheartedly agree with the Nuffield Trust that overfocus on the four-hour target does not improve emergency care and may lead to perverse actions to hit the target whilst missing the point. 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. 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."
Notes to editors
- The Nuffield Trust’s briefing is authored by Nigel Edwards, Ian Blunt and Leonora Merry.
- 'What’s behind the A&E ‘crisis’?’ is the third in a series of policy briefings on the issues and challenges the Nuffield Trust believes are critical to the longer term success of the health and social care system, and which any new administration following the election will need to consider.
- Nuffield Trust Chief Executive Nigel Edwards recently published an article in the Health Service Journal giving some examples from within hospitals of how the targets regime can distract staff and managers.