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Lop-sided logic: A&E and the 4-hour waiting time target

A&E Performance and the 4 Hour Target

Broadcast and newspaper headlines in the past couple of months have all been about pressures on A&E services. As ever with whirlwind media storms they typically tend to blow out before reasoned conclusions can be drawn.

Which leaves the question, what really does bedevil A&E? Is the problem facing the front-end of acute hospitals down to underfunding of emergency medicine; the ‘downgrading’ or closure of A&E units; fragmented and unresponsive primary care services; NHS 111 (more on this in a future blog); the payment or ‘tariff’ system; unprecedented patient demand; blockages including static or declining bed capacity and delays in transferring patients out of hospital or all of the above? 

The direction of NHS England is to ‘centralise’ or ‘standardise’ emergency provision around fewer locations and downgrading others into Minor Injury Units (MIU) or Urgent Care Centres (UCC). To critics this move is one which creates a ‘two-tier’ system. The logic is an economy of scale one and follows where earlier efforts in stroke and heart care have lead; namely centralise medical expertise and services in order to improve outcomes.

Two things are for sure – we shouldn’t expect ‘healthcare professionals’, code in this case for paramedics, doctors and nurses to work ‘harder’, they already are. Nor should we condemn people for using A&E services inappropriately in whatever numbers. Clifford Mann, the President of the Royal College of Emergency Medicine was absolutely right when he said last month: “I don’t think we should blame people for going to the emergency department when we (the system) told them to go there. It’s absurd.”

It is true that over time, we have both incrementally and intentionally designed a reactive, fire-fighting, hospital focused, medical health system, with care very much an after-thought. Hospitals declaring they can’t cope through issuing ‘major incident’ alerts is the predictable consequence of some pretty foolhardy thinking. One such example is the 4-hour waiting time target in A&E. Ludicrously this activity measure is regarded by many as both a good indicator of A&E performance and quality. It is nothing of the sort.

The 4-hour waiting time target is a nationally-derived arbitrary indicator. The NHS in England (or more appropriately individual NHS Trusts) has missed its four-hour A&E waiting time target with performance dropping to its lowest level for a decade. Figures show that from October to December 2014, 92.6% of patients were seen in four hours – below the 95% target. The performance is the worst quarterly result since the target was introduced in 2004. Viewed a different way, 9 out of 10 people who go to A&E get ‘seen and treated’, discharged or admitted within the 4-hour window. Interestingly, whether we actually solved their problem is not measured and consequently never recorded.

The waiting time target’s reductionist logic is simple. It is an arbitrary indicator which is set from outside the immediate organisation (hospital) or business unit (A&E). The hospital and A&E is then expected to achieve the target come hell or high-water, through greater effort by its employees. 

The reason this happens is because there is a mistaken belief that it is people themselves who are the limiting constraint on performance within organisations – they need to work harder or refrain from using services for reasons that are deemed ‘inappropriate’. The reality is that people’s performance or usage of a particular service is a consequence of the influence of other parts of the system, of which they form a part – policies, processes, procedures, systems, management. 

To use an analogy, if a person enters a 10 mile race, in the knowledge that they can only run 5, the only way they can finish the race is to ‘game’ or ‘cheat’ and catch a bus after the 5 mile mark. This is what happens in organisations. If the A&E arbitrary target for transferring patients to a ward is 4 hours, but the existing capability (if measured) is only 5, then in effect, the bus is a trolley parked in the hospital corridor. Only now it is alleged, the wheels are coming off. 

The other problem with arbitrary targets is that they are self-limiting. With no knowledge of patient demand and existing capability to meet that demand, the artificial target actually could be well within the range of what is improvement is possible. Paradoxically, setting a target can actually lead to under-achievement, in both people and organisations. 

To compound the problem, along with the deficiencies inherent in setting an arbitrary target, measuring and judging performance at a single static point or over a single period of time is also counter-productive. This ignores the nature of variation that exists in almost everything we do, individually and collectively within an organisation. Here averages distort unless viewed within the context of the overall distribution of performance and the underlying trend, viewed against the demand placed on the system at any given point in time. 

Whilst we can’t remove the 4-hour waiting time (the real limiting constraint), we should treat it as unavoidable system limitation but not drive performance solely on achievement of the arbitrary number. The alternative ‘solution’ is very straightforward – establish more insightful information streams and/or make better use of data in a more operationally meaningful way. Asking useful questions will help understand and in-turn resolve problems: 

  • Before measuring anything, ensure you are measuring the right thing. Is the 4-hour target measuring the right thing? Measure what matters to patients – do we actually know what this is? Is it quick diagnosis, speedy treatment, medical or psychological reassurance or getting help?
  • When it comes to measurement we first have to understand patient demand. Do we empirically know why people choose to use A&E (patient demands) in order to understand how A&E can be better designed to deal with these demands (capability)? Simply ranking demands by their perceived inappropriateness without understanding the patient context doesn’t solve any problem.
  • Measure your existing capability over time and understand the statistical variation that exists, against an understanding of demand.
  • Express what you measure statistically, based on the nature of the distribution of the thing being measured.
  • Unless you intend to change something and if you must set a target, understand what is within your current organisational or business unit capability.
  • If you want to set a target outside your current capability, then identify what you are going to change to achieve this objective.
  • Do not let the setting of a target act as a system constraint in itself.
  • Do not make a business out of it – the aim should be continuous improvement not ranking.

This alternative approach would require us to regularly understand and measure local demand placed on the system (find out from their perspective why people actually come to A&E, don’t assume to know the answers) and the local capability to respond to this demand. Is demand predictable over time? What is the current system capability (staff mix, capability to meet the nature of patient needs and resourcing) to successfully address this demand?

A sophisticated understanding of patient demand and the capability to meet it will provide providers and commissioners with the ‘business intelligence’ they need to have a more effective A&E service. It informs us as to the level and nature of professional expertise required in A&E and when; availability of appropriate test facilities and beds; person-centred processes to effectively meet needs and even how best to approach the design and layout of A&E.

One thing we can forget though: the growing trend to rebrand A&E Emergency Department (ED) – that has zero impact.

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Time for a dose of healthcare heresy

Help WantedRather predictably, the political debate over the latest crisis afflicting the NHS is generating more heat than light. Superficially rules. Discourse reduces itself to a reverse Dutch auction over who can promise more cash whilst at the same time compete to declare unconditional support for the NHS. Stephen Dorrell, former Health Secretary and Chair of the Health Select Committee is on to something when he was quoted in The Economist magazine last year saying that anyone who tries to introduce knowledge and understanding to the issues ‘quickly finds out what it must have felt like to be regarded as a heretic in a more religious age’.

Fast forward to the begininng of a new year and we see numerous acute hospitals triggering ‘major incidents’ in response to ‘unprecedented levels of demand’. Their response is often to hold ‘extraordinary meetings’ that occur with such regularly they lose their original connotation. Hopes that periodic cash injections like the multi-million ‘winter bed pressure’ funding or ad-hoc ‘urgent summits’ will resolve the current predictable morass facing acute NHS hospitals is a fool’s paradise.

In fact, we have worn out all the possible tinkering approaches: from restructuring and merging hospitals to only achieve bigger problems; deliberately fragmenting the healthcare system so that no one reliably knows who is doing what, why, when and where; successive bouts of IT-led change that cost more than the benefits derived by both patients or professionals; imposing arbitrary targets that distort behaviour (such as the ubiquitous 4-hour waiting time indicator or referral to treatment times) and lead to ‘gaming’; increasing capacity which makes performance worse to rationing care (particularly in community and social care settings) that results in a false economy.

Indeed, the belief that we can simply talk or spend our way of trouble is indicative of a paucity of understanding. It is worth remembering that since 2000 we have tripled public expenditure on the NHS but not experienced service improvements consummate with such investment. Years later we still feel the need for calamity talks and emergency bailouts.

Such inertia and belief in extra expenditure is a costly distraction from consideration of the real problem facing the NHS; namely that we have an outdated model of healthcare that is capacity-constrained not demand-led. The current crisis of increasing attendance and admission rates (not the same thing as increasing numbers of people) to A&E is one consequence but not the primary cause of the turmoil.

It is possible to achieve the holy grail of healthcare: better care at less cost but this will require a complete resetting of how we intelligently manage, lead and apportion expenditure across the whole system. The only way that will work is to understand the nature of patient demand that appears and then develop a coordinated healthcare response (through redesigning broken systems, processes and payment mechanisms) that meets local needs – no more, no less.