Four Hours in A&E

The NHS’s four-hour target for A&E admissions has entered the spotlight, after the Health Secretary Matt Hancock suggested that he was considering scrapping the metric in favour of some other, unspecified clinically appropriate target. The existing target expects that 95% of admissions are triaged – admitted, referred, or told to sod off – and moved along from A&E within four hours of presenting. Notionally, this seems a sensible target.

When a metric becomes a target, it ceases to be a good metric.
Goodhart's Law

However, when metrics such as this become themselves the target of optimisation, they have a habit of ceasing to be good metrics – people will try and cheat, and put their efforts in to improving the metric rather than the outcome it was trying to approximate, i.e. to make it seem as though all is going better than it actually is. In this context, what does that look like?

Hospital managers keen to hit the targets may place disproportionate emphasis on pushing patients through the emergency department without due regard for where they end up and how. Much-needed medical staff are moved from ward cover, where they would deal with any medical emergencies that arise, to clerking-in new patients from the emergency department that may be less-unwell than those already admitted. This could be a spur of the moment change, if it looks like A&E is going to breach the target on a bad afternoon. For instance, one doctor at a London hospital tells of patients having been hurried out of A&E before their four hours lapsed, when it was perhaps not the clinically safest thing to have done so.

We will be judged by the right targets. Targets have to be clinically appropriate. The four-hour target in A&E – which is often taken as the top way of measuring what’s going on in hospitals – the problem with that target is that increasingly people are treated on the day and are able to go home. It’s much better for the patient and also better for the NHS and yet the way that’s counted in the target doesn’t work.
Matt Hancock, Health Secretary

None of this is to say that that this metric is worthless, nor that there hasn’t been a steady decline in performance against this target for years. Scrapping the target because it doesn’t look good for the government’s record on healthcare would be unsavoury to say the least. It also goes without saying, that four hours is about three and three quarter hours too-long to wait for the most severe conditions, such as heart attacks, strokes and traumatic injuries. But it is to say that the target might be hindering, rather than helping.

Unfortunately, a lot of what falls to the doctors and nurses in A&E are cases that have fallen through the cracks in other services. Doctors tell, for instance, of elderly people being admitted to A&E because they’re off their baseline or not coping well. Perhaps in an alternate universe where the healthcare system isn’t on its knees and has beds abound, this would be fine – however, given the current state of despair at the way the NHS is headed, these are perhaps the kinds of admissions that should instead have been handled outside of a hospital by social services and other care-givers.

Similarly, people go to the hospital instead of their GP because they know they’ll at least be seen some time that day. One person claiming to have had to wait 12 hours to be seen clearly can’t have been that unwell… You can see the logic to asking someone that is happy to wait to get their possibly-broken finger seen wait more than four hours, if there’s a backlog of people with shortness of breath and a tight chest.

One can argue that this target, introduced in 2004, has forced the issue of A&E performance and thus encouraged investment in emergency departments. NHS funding has been increased year-on-year by each government since 1955, at an average of around 4% per-year, although the current rate of around 2% is a near historic low.

This monotonic increase is not necessarily enough, as the minimum to maintain the same standard of care year-on-year would assumedly be to increase spending to accommodate inflation, new treatments and the growth and demographic shift of the population – this could amount to more than 4%. Still, there is an undeniable and precipitous decline away from hitting this 95% target, to being at 80 to 87% on average throught the year.

There is also the implicit assumption that A&E waiting times are the big, or even a big problem. We must maintain an open mind and consider that the struggling A&E departments might not be the problem we ought to address foremost. It’s a topic for another article, but the NHS’s problems are certainly not funding alone.

If the Health Secretary and his department want to replace the four-hour yardstick with a more refined instrument, then we should encourage this. It is not a perfect target, and has some significant downsides. If both incentives against unnecessary use of A&E, and a drive for improved patient outcomes can be accommodated within a new metric, we should welcome it. If it is instead just a punt of the goalposts down the hill, we should certainly not welcome it.

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Four Hours in A&E

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