Jeremy Hunt says that the 4-hour A&E target is only meant for urgent cases. Perhaps he is right as this is what clinicians have been saying and perhaps we need to listen to them.
Each target introduced by government has been developed based on excellent evidence and for a reasonable purpose at the time. A prime example is the four-hour target set nationally for A and E. This is reported nationally and is used as a bench marking tool of the performance of Trusts.
Initially this target was introduced by the Labour Government in 2004, as it was identified that there was a requirement to promote improvements in A&E departments, which had suffered underfunding for a number of years. Initially set as 98% of patients seen must be treated, admitted or discharged in under four hours, this was amended to 95% in June 2010.
The target, accompanied by extra financial support, was a key plan to achieve the improvements. This was laudable and brought about dramatic changes, 52% to 98.2% within 2 years, but had dropped to 91.8% by 2014 as funding was removed.
So what has been the impact of this target? The initial monetary investment is no longer in the system and public perception, demand and access to healthcare has changed over the last ten years. There has an unprecedented rise in the older population, long term conditions alongside an increasing population base. The increased need for emergency services has led to professional management of the hospital bed stock. There has been an increase in bed managers, whose role is to ensure patients are placed promptly in appropriate beds; in addition to discharge coordinators to help overcome obstacles to patients being discharged when ready.
There are further elective targets introduced by subsequent desires to improve patient experience and safety. The 2-week rule for cancer patients ensures that patients suspected of a possible cancer are seen within this time period but some patients reflect that this increases anxiety and it relies on the expertise of the referring clinician. There is an 18-week target from referral to treatment for elective patients of any type. In addition, any patient waiting more than 52 weeks incurs a breech, reportable centrally. There are penalties and fines attached to breaches of any of the targets.
So how are these targets achieved? Clinically but also there are numerous layers of managers keeping track of the data in archaic databases that are not reliable and therefore require checking by hand to reduce inaccuracies.
There is a tension in these emergency and elective targets as these are within the same bed base and by the same clinicians.
In parallel, the reduction in the number of NHS beds by 17% (21k) has been facilitated by the change of pathways to day case management. The closure of beds and the reduction of associated staffing is also a prime opportunity to save money and so is championed but are unique opportunities, as budgets are then reduced. incurring a cost pressure if extra beds are needed.
So what are the ramifications of these targets? There is no doubt that there was an initial improvement in clinical care but this has not been an easily sustainable effort. Currently there is a great deal of management, clinician and financial investment to ensure that these targets are not only achieved but also reported.
The real ramifications are the loss of trust and value of each other. There is a feeling that the public and patients do not respect the NHS as there are high non-attendance rates not just as outpatients but also of elective surgery. It appears that the public have become used to the NHS just offering another date if they don’t attend. The lost opportunity is compelling as it blocks another patient from attending on that date but also the Trust from claiming an income for that time period.
There are many managers and NHS clinicians working very hard and often putting in extra (unpaid) hours to make sure they deliver the best. They wish to drive excellence but sadly we communicate by email and have lost the relationship with each other. The managers are responsible for managing all aspects of hospital care and that includes staffing. And managers are employed to manage these managers. The top heavy approach with central targets has pushed to try and add another couple of patients into an already overbooked clinic so that it can be achieved. NHS professionals of all specialities are often short staffed but always go that extra to deliver a high standard of care and therefore do not understand or accommodate this pressure.
There is a distrust of clinicians, so a desire to encourage an extra ward round to discharge a few more patients is requested and due to the pressure managers may resort to doing extra rounds on a clinician’s behalf. There is a loss of value, respect and trust between clinicians and managers but both are working to the same goal.
And this is now developing at pace.
And we have a healthcare system with GP practices and social care. They are also suffering the need to demonstrate target achievement. For General Practices, this has incurred income losses as these run as small businesses. The partners of several practices have not drawn a salary for several months to ensure the salaried staff get paid and some sadly have shut. On the brink of chaos with staff shortages, the current request to ensure 7/7 deliverability will demoralise the NHS workforce even more.
The intangible outcome is a sick NHS, a claustrophobic environment which is constantly under scrutiny.
The NHS should now be allowed to deliver targets set locally to achieve excellent care. The Five Year Forward view is very laudable and the Vanguards, if allowed to develop local solutions, may succeed. The NHS needs to be funded with a long-term strategy and we need to eliminate the wastage of money that currently occurs.
There is only one aim within the NHS. That is to deliver the best care within a financial envelope and deliver this free at the point of care. Let’s assume that all NHS Clinicians will do their jobs as that is what we are trained to do. Let’s assume that managers will manage the service and developments. Let’s assume that the public and patients value the NHS.
Put that trust back in the system and get rid of the ghosts and we may well succeed.