Time is precious, and much more so when you have an “emergency.” In an emergency, the quicker you are seen and the faster you are treated, the better it is for you. These simple tenets were behind what would turn out to be an expensive exercise, initiated under UK Prime Minister Tony Blair, that was aimed at reducing waiting times in the emergency department.
The national Emergency Services Collaborative programme was set up by the NHS Modernisation Agency in 2002 to ensure that, by the end of 2004, nearly all patients were to be seen, treated and discharged or admitted within 4 hours of arrival in the emergency department. The programme began with the first of six waves-of 30-35 NHS trusts per wave- in October 2002, with all waves becoming fully operational by July 2003.
The belief was that, through an analysis of the “patient journey,” delays and bottlenecks in the various processes involved could be identified and dealt with systematically. Terms like lean thinking and process re-engineering were the flavour of the day. Patients were assigned or “streamed” to various groups, each requiring different levels of assessment, investigation and treatment. Various pathways were developed for each of these patient groups.
Initially, the 4-hour target was required to be met for 98% of all those attending the emergency department, irrespective of presenting condition. For a few years, the project was a success and the NHS offered the most rapid emergency department treatments in any major industrialised country.
This initial target proved to be unsustainable. The target was accordingly relaxed in 2010 to apply to 95% of all new attenders. Failure to meet this target led to financial penalties and other sanctions against individual NHS trusts, and encouraged perverse incentives to manipulate the figures through processes of inventive activity and creative accounting. Meeting the target often merely involved manipulating the actual process of patient throughput and had nothing to do with improving the quality of care and its outcomes. This frequently led to distorted clinical priorities. In some cases patients were moved too quickly and unsafely before their conditions had been stabilised, just to ensure that targets were met.
The 4-hour target has not been met in the majority of NHS trusts in England since July 2015, and performance has decreased year-on-year. Suggested approaches to manage growth in demand for emergency services and improve patient flows have largely been ineffective. The ostensible reason for this was perhaps the fact that the system as designed was already configured for maximum efficiency given the resources available.
NHS England suspended from January 2018 to April 2019, and is now planning to abolish, the 4-hour target, a move which has been opposed by the Royal College of Emergency Medicine .Changing the goalposts is a convenient way to deal with a system that is failing to deliver. There is a feeling that this may divert resources away from emergency departments and may not allow for improvements in patient flow and system performance.
In April 2019, NHS England selected fourteen NHS trusts to pilot a new set of standards, which includes the average waiting time for all patients. This review of emergency standards was announced by the Prime Minister in June 2018. The due date for the implementation of changes is scheduled October 2019, almost simultaneously with Brexit! This is yet another example of the continued review and restructuring that has been going on within the same outdated and simplistic paradigm for emergency care in the nation.
The issue of the 4-hour target once again directs attention to the problems of a demand-supply mismatch within the NHS, an issue which has frequently been dealt with in a reactive fashion without a clear long-term vision. It is, however, important that fundamental goals of equitable access to good-quality efficient care are not subverted in the course of the latest initiatives.
Ashis Banerjee (ex-NHS; life was once dominated by targets)