5Targets in urgent and emergency care
Four-hour waiting time standard
138.The four-hour waiting time standard is the headline measure by which the success or failure of emergency departments, hospitals, and health systems is judged. Despite the challenging nature of the target and it placing tougher demands on hospitals than in many other comparable countries, we heard broad support for maintaining the standard.175 Homerton University Hospital Trust argued that benchmarking performance against the four-hour waiting standard is a vital component of ensuring a safe system and positive patient experience. They said that in managing the urgent and emergency care system the Government should
maintain a strong focus on emergency care over winter and maintain the 4-hour target as an indicator of system resilience. Without this there would be a risk of system-wide collapse and patients suffering.176
139.Although outright gaming of the four-hour target was thought to be limited, in discussion with the national policy experts we met in Luton we heard examples of where the four-hour target can distort clinical priorities or drive unnecessary admissions to avoid breaching the target—a practice often referred to as ‘admit to decide’. This occurs instead of the more desirable practice of ‘decide to admit’.177
140.We heard calls during our visit for more nuanced targets to be developed, for example setting standards for treatment and outcomes for specific conditions across the entire patient pathway.178 Our predecessor Health Committee’s report of 2013 found that the four-hour target “does not provide a full measure of service quality” and the “key indicators of hospital performance should be based on a broader assessment of patient outcome and experience”.179
141.In oral evidence Professor Keith Willett, NHS England’s Medical Director for Acute Care, said that:
the performance in an A&E department is almost wholly dependent on its relationships and its working with the other departments of the hospital and the other providers in the healthcare economy.180
Conclusions
142.As noted in chapter 1, the Royal College of Emergency Medicine has described the four-hour waiting standard as “a useful proxy measure of crowding” and in 2013 our predecessor Health Committee concluded that it “retains its value as a basic measure of performance”.181 We believe that the standard still serves as a useful measure of pressure in the entire system, an objective for patient safety and a helpful gauge of patient experience. Meeting the standard should be regarded as everyone’s business.
143.Considering the continued value of the four-hour waiting time standard, our predecessor Committee concluded that “the key indicators of hospital performance should be based on a broader assessment of patient outcome and experience”. The evidence we have heard during this inquiry has emphasised that emergency department performance is dependent upon relationships that exist across an entire health economy. Responsibility for achieving good performance in an emergency department lies not just within that department, nor even with the trust alone, but with individuals and teams across the whole health and care system. It is everyone’s business, including those in Government responsible for policy making on public health and prevention. We support retaining the four-hour waiting time standard in emergency departments. We recommend, however, that evidence-based standards of performance should be developed which allow for a better assessment of the performance of the wider health and social care system in relation to urgent and emergency care.
Ambulance service targets
144.The necessity of developing system-wide measures of performance is exemplified by the problematic nature of the response time targets which shape the allocation of resources and working practices of ambulance trusts. The Government’s evidence noted that a pilot scheme designed to review the coding of ambulance calls and dispatch is one of the five interventions designed to help improve the urgent and emergency care system.182 In oral evidence Professor Willett outlined the failings associated with the existing target mechanisms, which can require attendance by an ambulance within 8 minutes for calls graded at the most serious level (red 1):
Fifty-eight per cent of all ambulances in England that are dispatched are dispatched on blue lights and two tone sirens, to go to an emergency. The number of patient calls that might benefit from a response of that urgency, to get there in eight minutes, is probably less than 2%, and certainly no more than 6%. Fifty-eight per cent of ambulances go out, and that is because they are trying to meet the eight minute target. In fact, 25% of the ambulances we dispatch never get to the scene because another vehicle has got there first or, it turns out, by the time they have found out what is wrong with the patient that they are not needed. That means we are currently sending multiple vehicles to one call, just to try to meet the standard.183
145.Professor Willett’s description of the system is aligned with that of the East of England Ambulance service, representatives of which observed during our visit to the Bedford ambulance station that achieving time drives behaviour and not clinical outcomes.184 In Bedford it was noted that different targets apply elsewhere in the UK and strict time-based targets in England may be driving demand.185
Conclusions
146.Professor Willett said that part of the ambulance response target includes the requirement that call handlers decide whether a vehicle should be sent within 60 seconds of the call being connected. In reality, Professor Willett said, making a sensible judgement within 60 seconds is often not feasible, so the NHS England pilot scheme has relaxed that aspect of the target, allowing more time for decisions to be made.186 We consider that this is a wise approach, as the existing target regime for the ambulance service can distort clinical priorities and makes poor use of resources.
147.Neither ambulance response targets nor the four-hour waiting standard in hospital can illustrate effectiveness of clinical decision making across the patient pathway. The challenges associated with handover delay at the beginning of the patient journey and delayed transfers of care at its end illustrate why much broader standards are required to measure the successful operation of the system as a whole, as we have recommended in paragraph 143 above.
148.It is welcome that NHS England has launched pilot schemes to explore how the ambulance service can be utilised more effectively. The pilots should be monitored closely so that initiatives which achieve their objectives can be replicated across all parts of the country as soon as possible. Too often ambulances are despatched inappropriately or are left waiting outside hospitals. This wastes the skills, time and resources available within the service. Reform of the existing target regime for ambulance providers in combination with tackling handover delays should be prioritised by NHS England. This would help to remove the practical barriers that limit the ability of ambulance providers to ‘see and treat’ patients without having to convey them to hospital.
175 Monitor, International comparisons of selected service lines in seven health systems, October 2014, Annex 5
177 Note of Committee visit to Luton and Bedford
178 Ibid
179 Health Committee, Second Report of Session 2013–14, Urgent and emergency Services, HC 171, para 67
180 Q5
181 Health Committee, Second Report of Session 2013–14, Urgent and emergency Services, HC 171, para 67
183 Q38
184 Note of Committee visit to Luton and Bedford
185 Note of Committee visit to Luton and Bedford
186 Q39
31 October 2016