NHS targets

Conservative governments set targets for the NHS in the 1990s – for example, guaranteeing a maximum two-year wait for non-emergency surgery and reducing rates of death from specific diseases. The Blair government introduced far more targets and managed performance far more aggressively - a management regime sometimes referred to as 'targets and terror'. Targets have been blamed for distorting clinical priorities, and in particular for one organisation achieving a target at the expense of another. For example, ambulances have been forced to queue up outside a busy emergency departments so that the ambulances might not be able to meet their target in responding to emergency calls, but the hospital can meet its A&E target. Excess emphasis on the targets can mean that other important aspects of care, especially those not easily measured, may be neglected.[1] NHS England under the Conservative governments reduced the number of targets, in particular removing most of those relating to health inequality, and encouraged a system wide approach. However shortage of staff and funding meant that performance against targets declined.[2] Guidance published in February 2018 conceded that most of the targets would not be met before April 2019.[3]

The NHS Constitution for England specifies waiting times in the accompanying Handbook, but does not provide a remedy should they be breached.

Accident and emergency departments

A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. The original target was set at 100%, but lowered to reflect clinical concerns that there will always be patients who need to spend slightly longer in A&E, under observation. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, and admitted or discharged in under four hours.[4] The target was further moved to 95% of patients within four hours in 2010 as a result of the coalition's claims that 98% was not clinically justified.[5] Trusts which failed to meet the target could be fined. In July 2016 NHS trusts were set new "performance improvement trajectories". For 47 of the 140 trusts with "type one" major A&E facilities this meant a target of less than 95% waiting under 4 hours.[6] In January 2017 Jeremy Hunt announced that the target would in future only apply to "urgent health problems".[7] In January 2018 only 77.1% of patients were admitted or discharged within four hours, the worst ever performance for type one A&E departments. [8]

In Scotland the target is for 95% of A&E patients to be either admitted, transferred or discharged in four hours. It was last met in July 2017.[9]

Objective

The UK Labour government had identified a requirement to promote improvements in A&E departments, which had suffered underfunding for a number of years. The target, accompanied by extra financial support, was a key plan to achieve the improvements. Tony Blair felt the targets had been successful in achieving their aim. "We feel, and maybe we are wrong, that one way we've managed to do that promote improvements in A&E is by setting a clear target".[10]

48% of departments said they did not meet the target for the period ending 31 December 2004.[11] Government figures show that in 2005-06, 98.2% of patients were seen, diagnosed and treated within four hours of their arrival at A&E, the first full financial year in which this has happened.[12]

The 4-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labeling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[13]

Although the four-hour target helped to bring down waiting times when it was first introduced, since September 2012 (after the introduction of the Health and Social Care Act 2012 and top-down reorganisation of the NHS) hospitals in England struggled to stick to it, prompting suggestions that A&E departments may be reaching a limit in terms of what can be achieved within the available resources.[14] The announcement of the reduction of the target from 98% to 95% was immediately followed by a reduction in attainment to the lower level.[15]

By December 2014, the number of patients being treated within four hours had fallen to 91.8%.[16]

From December 2015 the 95% target over England as a whole was missed every month. From October 2016 to December 2016 only 4 out of 139 hospitals with major type 1 A&E departments met the target.[17]

Missing the target

According to the BMA[11] the main reasons for not reaching this target are:

  • Not enough inpatient beds
  • Delayed discharges
  • Delay in accessing specialist opinion
  • Not enough nurses
  • Not enough middle grade doctors
  • Department too small
  • Delay in accessing diagnostic services

In 2014, research conducted by QualityWatch, a joint programme from the Nuffield Trust and the Health Foundation, tracked 41 million visits to A&E departments in England in order to better understand the pressures leading to increased waiting times and breaches of the four-hour target. Researchers identified a rise in older patients and related increase in long-term conditions as key factors, alongside extremes of temperature (in both summer and winter) and crowding at peak times. They noted that the majority of pressure was falling on major A&E units, and proposed that rising demand as a result of ageing and population growth may be pushing already stretched emergency departments beyond maximum capacity.[18]

In July 2017 the Royal College of Emergency Medicine produced a report saying that the NHS needed at least 5,000 more beds to achieve safe bed occupancy levels and hit the four-hour target.[19]

Pressure

Even though exceptions are allowed to the targets, concerns have been raised that the target has put pressure on A&E staff to compromise patient care. A significant proportion (90%) of A&E consultants welcomed the four hour target in a study but felt that 98% was too high a target.[10]

Twelve hour target

At the same time as the four target was introduced a target that no patient should wait longer than 12 hours before they are admitted to a ward, if that is required, was introduced. Between January and March 2012 only 15 patients in England waited more than 12 hours, but in the same months in 2017 1,597 patients breached the target.[20] In January 2018 1,043 patients waited over 12 hours for a bed, the worst figure ever recorded. 272 were at University Hospitals of North Midlands NHS Trust.[21]

Planned treatment

Over four million patients were waiting for non urgent hospital care as of July 2017. The Royal College of Surgeons together with other medical groups fear patients are waiting longer in anxiety and pain for hospital procedures.[22] The target was that 90% of patients admitted to hospital for treatment and 95% of those not admitted should receive consultant-led care within 18 weeks unless it is clinically appropriate not to do so, or they choose to wait.

One year wait

In December 2017 there were 1,750 patients waiting a year or more, the highest total since August 2012. 242 were at Imperial College Healthcare NHS Trust, 156 at Mid Essex Hospital Services NHS Trust and 114 at Royal Cornwall Hospitals NHS Trust. 11.8% of those waiting for a procedure had waited 18 weeks or more.[23] By March 2018 there were 2,647. The largest numbers were at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Imperial College Healthcare NHS Trust, King's College Hospital NHS Foundation Trust, Royal Cornwall Hospitals NHS Trust and East Kent Hospitals University NHS Foundation Trust.[24]

Six month wait

445,360 had been waiting six months or more by the end of December 2017 - three times more than in 2013. The President of the Royal College of Surgeons said it was “completely shameful” that patients were being forced to resort to paying for operations the NHS should provide as these waiting times led to an increase of 53% between 2012 and 2016 in the numbers paying personally for private operations.[25]

Cancellations

Between January and March 2018 25,475 operations were cancelled at the last minute for non-clinical reasons by NHS providers - 20% more than the first quarter of 2017, and the highest number since records began in 1994-95. This was 1.3% of all elective activity - the highest proportion recorded since 2004-05.[26]

See also

NHS ambulance services#Targets in England

References

  1. ↑ "Have targets improved NHS performance?". Kings Fund. 2010. Retrieved 22 December 2017.
  2. ↑ "Check NHS cancer, A&E and operations targets in your area". BBC News. 7 December 2017. Retrieved 22 December 2017.
  3. ↑ "NHS allowed to miss A&E target for another year". Health Service Journal. 2 February 2018. Retrieved 2 April 2018.
  4. ↑ The Four Hour Target in Accident and Emergency
  5. ↑ https://www.theguardian.com/society/2013/apr/02/nhs-four-hour-targets-aande
  6. ↑ "Third of providers will still miss A&E target in March 2017". Health Service Journal. 21 July 2016. Retrieved 19 March 2017.
  7. ↑ "Jeremy Hunt ditches four-hour target as A&E crisis deepens". Guardian. 9 January 2017. Retrieved 19 March 2017.
  8. ↑ "Trolley waits soar to record high". Health Service Journal. 8 February 2018. Retrieved 2 April 2018.
  9. ↑ "SNP attacked over year of missed NHS targets". Scottish Express. 29 July 2018. Retrieved 14 August 2018.
  10. 1 2 BBC NEWS | Health | Target 'putting A&E care at risk'
  11. 1 2 BMA - BMA survey of accident and emergency waiting times, March 2005
  12. ↑ BBC NEWS | Health | A&E success 'not sustainable'
  13. ↑ Mayhew, Les; Smith, David (December 2006). Using queuing theory to analyse completion times in accident and emergency departments in the light of the Government 4-hour target. Cass Business School. pp. 2, 34. ISBN 978-1-905752-06-5. Retrieved 2008-05-20.
  14. ↑ Blunt, Ian. "Why are people waiting longer in A&E?". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 2 February 2015.
  15. ↑ Woodcock, Thomas; Poots, Alan J; Bell, Derek (March 2013). "The impact of changing the 4 h emergency access standard on patient waiting times in emergency departments in England". Emergency Medicine Journal. 30 (3): e22–e22. doi:10.1136/emermed-2012-201175.
  16. ↑ "Indicator: A&E waiting times". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.
  17. ↑ "What's going on in A&E? The key questions answered". King's Fund. 6 March 2017. Retrieved 19 March 2017.
  18. ↑ Blunt, Ian. "Focus on: A&E attendances". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.
  19. ↑ "NHS needs 5,000 more beds, warn leading A&E doctors". Health Service Journal. 7 July 2017. Retrieved 23 August 2017.
  20. ↑ "12-hour patient waits in A&E increase by 10,000% in five years". Healthcare Leader. 25 September 2017. Retrieved 22 December 2017.
  21. ↑ "Trolley waits soar to record high". Health Service Journal. 8 February 2018. Retrieved 2 April 2018.
  22. ↑ Patients waiting for planned NHS hospital care top 4m for first time in a decade
  23. ↑ "Year-plus elective waiters at highest number since 2012". Health Service Journal. 8 February 2018. Retrieved 2 April 2018.
  24. ↑ "Year-plus waiters rise 75 per cent". Health Service Journal. 31 May 2018. Retrieved 17 August 2018.
  25. ↑ "Numbers 'going private' for surgery soaring as NHS rationing deepens". Telegraph. 11 August 2018. Retrieved 14 August 2018.
  26. ↑ "Last minute cancelled operations hits highest rate since 2005". Health Service Journal. 10 May 2018. Retrieved 13 August 2018.
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