The emphasis on the totemic target of deciding on whether to admit patients to hospital within four hours of presenting at A&E has become disproportionate.
A briefing by the Nuffield Trust argues that new approaches to performance management, with other measures given equal status to the four-hour target, should be adopted.
It says England’s A&E system is near crisis. With the financial squeeze set to continue, there is no relief in sight if the government continues with the current approach.
Demand isn’t the main issue, it says, it’s the lack of hospital space and the need to improve discharge that needs to be tackled.
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% 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.
Nigel Edwards, CEO at the Nuffield Trust, said: “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.”