Performance in England’s A&E departments has fallen to new lows after a decade of under-funding and real terms cuts in spending alongside an increased population and a rising proportion of older people.

The target of treating or discharging 98%, and later 95% of A&E attenders within 4 hours has not been reached by England’s NHS since 2015. So ministers such as Matt Hancock, despairing of ever regaining the consistently high performance levels achieved in the late 2000s, have looked to ditch the embarrassing target – effectively moving the goalposts – rather than tackle the underlying lack of resources.

The Royal College of Emergency Medicine is one of a number of professional bodies that have challenged Matt Hancock’s apparent wish to ditch the 4-hour target that is enshrined in the NHS Constitution. Dr Katherine Henderson, the president of the RCEM said:

“So far we’ve seen nothing to indicate that a viable replacement for the four-hour target exists. Rather than focus on ways around the target, we need to get back to the business of delivering on it.”

Susan Crossland president of the Society for Acute Medicine, which represents specialists in hospital care of the very sick, put it more bluntly: “Potentially scrapping the target because it is no longer being met shows the disregard this current government has for improving patient care.”

Crucial

The Royal College of Physicians, stressed that the target had “played a crucial part in driving improvements in waiting times for patients,” and the BMA has also spoken out against dropping or diluting the target.

The RCN’s Emergency Care Association, representing 8,000 A&E nurses, told the HSJ that “it could cause significant detriment to patient safety within our emergency departments if the four-hour target was abolished.”

The problem in A&E is not the large numbers of minor cases, so-called “Type 3” A&E attenders, who might otherwise have been treated by GPs or by nurses in an urgent treatment centre: almost all trusts consistently treat and discharge close to 100% of them within the 4 hour target.

Instead, perversely, it is those with the most serious health needs, the Type 1 patients, who face the greatest delays, mainly for lack of beds to admit them to hospital.

But Britain is not alone in struggling to deliver prompt emergency care: according to a new study recently published by the Institute of Fiscal Studies:

“there remains dissatisfaction in most health care systems with the level of crowding in EDs and the speed with which cases are resolved.”

What was unique to England’s NHS was the imposition of the 4-hour target: but while those embarrassed by performance figures like Hancock try to argue it is now out-dated and clinically inappropriate, the IFS report, researched jointly with Cornell University and the Massachusetts Institute for Technology (MIT) shows that it has brought significant and tangible benefits to patients:

“We study one type of regulatory intervention, the four-hour wait target policy enacted in England. We find that this target had an enormous effect on wait times …

“We find this target led to a significant rise in hospital admissions. …

“At the same time, we find striking evidence that the target is associated with lower patient mortality. There is a 0.4 percentage point reduction in patient mortality that emerges within the first 30 days, amounting to a large 14% reduction in mortality in that interval. …

“While modest, this effect is large relative to the extra spending…

“Finally, we … show that this effect arises through reduced wait times, not through increased inpatient admissions.” (p29-30)

The researchers find that the target creates a characteristic – and apparently unique – “spike” in numbers of admissions  as the 4-hour target grows closer, with more than 10% of patients being admitted in the final 10 minutes before the deadline is reached.

“This spike is unlikely to naturally occur, and is instead induced by the target. We cannot illustrate the absence of this spike prior to the wait times target, since we do not have systematic data available from that period. But it is worth noting … that such a spike is not present in data on ED wait times from a major U.S. hospital.” (p11)

The researchers estimate that the target has been successful in reducing average waiting times by around 20 minutes.

Increased admissions

It’s clear from the figures that one impact of this has been to increase the numbers of patients admitted, including some with relatively minor needs, and as a result increased spending and marginally increased average costs of A&E services (by an estimated 5% or so)

However the tangible health gain flowing from the reduced waiting times is a new finding from the research. One of the research team, George Stoye, reports in a summary of the paper that:

“The target also led to large reductions in the number of patient deaths. Patient mortality within a year of visiting A&E fell by 0.3 percentage points among the patients affected by the target, reducing the probability of mortality among this group from 9% to 8.7% as a result of the policy.

“Given the large number of A&E patients affected by the target each year, these estimates imply that the target resulted in around 15,000 fewer deaths in 2012-13 alone.”

The paper goes on to ask the question of whether it is lower waiting times or the fact that more patients are admitted to hospital that saves lives?

Importance of waiting times

Some complex statistical comparisons produce evidence that larger mortality reductions flow from the reduced waiting times: there is no relationship between numbers of admissions and deaths.

It also shows that the biggest reductions in mortality rates are among patients with potentially serious conditions that benefit from timely treatment, with the largest impacts found among sepsis, heart attack and stroke patients:

“By contrast, there is no impact on patients with a number of different cancers, serious conditions which are less time-sensitive…”

In addition to researchers shoot down any suggestion of simply “fast-tracking” patients with the most serious and time-sensitive conditions:

“There is often confusion over the exact diagnosis of patients upon arrival, and identifying which patients are covered by the target might not always be obvious (and could even lead to hospitals ‘manipulating’ recorded diagnoses to better hit the target). Indeed, the current policy appears to be so effective because it means that patients who should be treated quickly – but who are not diagnosed or treated as quickly as they would optimally be – are treated faster.”

In other words simply fast-tracking treatment of patients with specific conditions but not others “risks losing the benefit that the current policy provides for hard-to-diagnose patients.”

The unexpected intervention of the IFS, with its reputation for impartiality and reliance on solid figures, further strengthens the hand of the professionals before the real showdown with Hancock when the results of the ongoing “review” are revealed.

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John Lister
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