The four hour target is dead; long live the four hour target!

Citation

Harrop, N. (2013), "The four hour target is dead; long live the four hour target!", Clinical Governance: An International Journal, Vol. 18 No. 4. https://doi.org/10.1108/CGIJ-07-2013-0024

The four hour target is dead; long live the four hour target!

Article Type: Editorial From: Clinical Governance: An International Journal, Volume 18, Issue 4

The papers published in this edition of CGIJ are mainly from contributors to an international symposium on quality and safety in hospital emergency departments (known in the UK as Accident and Emergency or A&E departments), held by the International Federation for Emergency Medicine (IFEM) in London in November, 2011). The symposium brought together delegates from Northern America, Australasia, Africa and Europe with the aim to develop “a universal framework, applicable across the globe, for quality and safety in the emergency department”. At the time of this edition’s publication, the UK parliament and the NHS have just received the report of its Medical Director, Professor Sir Bruce Keogh, from his mortality review of the NHS hospitals with the highest standardised hospital mortality ratios (HSMR) amongst patients admitted as emergencies.

The Keogh review follows the public inquiry, led by Robert Francis, into the failings responsible for intense public dissatisfaction and exceptionally high HSMR at the Stafford hospital (a large hospital in the UK midlands). Politicians and the media have been incensed by the supposition that higher HSMR must imply unnecessary patient deaths on a massive scale. In subsequent statements to the media, Sir Bruce has described the use of HSMR to quantify avoidable deaths as “clinically meaningless and academically reckless”.

Amongst the failings, in Stafford, Francis (2010) incriminated certain aspects of the A&E department (Francis, 2010, pp. 38-53). Especially, Francis incriminated the poorly-planned utilisation of A&E staff and workspace to constitute Clinical Decision Units, whose proper purpose was to help A&E staff limit their demands on scarce hospital beds. The unintended consequence had been to establish a space where managers could comply with an enthusiastically-driven national “four hour target” by containing patients, destined for admission, until a ward bed could be found. This target, introduced to enhance public confidence in the NHS and in the government of the time, mandated chief executives to eradicate long waits in A&E, by imposing a guillotine on patients’ transit through the emergency department prior to admission.

The UK government’s independent regulator of hospital quality, the Care Quality Commission, has been exposed as having been hitherto unable to deploy effectively the expertise required by its role.

Meanwhile, the Health Secretary has raised a storm by citing the mass withdrawal of GPs from provision of surgery-based Out of Hours Care as a cause of rising demand for unscheduled, hospital-based care.

It emerged in May, 2013 that the NHS 111 demand management system for unscheduled care had stalled after its implication in 22 serious untoward incidents and three deaths. Provided by non-clinical reception staff who operate risk-averse, computerised decision support algorithms, NHS 111 has been able neither to cope with demand nor to stem the rising tide of emergency hospital attendances.

How is the world’s biggest state funded healthcare system responding to the unfolding crisis? First, 11 of the major hospitals with high mortality investigated by Keogh will be subject to “special measures”, with intrusive supervision from external governance teams. Second, the government has established a Chief Inspector of Hospitals in the person of Professor Sir Mike Richards. In May, 2013, the Chief Operating Officer of the NHS (Hakin, 2013a) wrote a directive which recognised that “long waiting times in A&E departments (often experienced by those awaiting admission and hence ill patients) not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness”. In a policy document for the NHS, Hakin (2013b) proposes a national recovery and improvement plan, whose chief indicator “that patients are being treated quickly” will be performance against the four hour national target standard. This standard, controversial both for its rationale and the manner of its implementation (Mason et al., 2012; Cooke, 2013) was jettisoned in April, 2011 (Lansley, 2010; Hughes, 2012) in favour of a suite of performance indicators provided by the College of Emergency Medicine. There is no sign, yet, that this target will be dropped a second time. Indeed the decline in national performance against this target over the past year has become a weapon in the internecine struggle between opposing political parties, each claiming to be the better guardian and steward of the nation’s health service.

Francis directed special criticism because strategic planners and hospital executives had prioritised the production of favourable performance figures (including figures for compliance with the national four hour standard) over authentic aspects of patient care.

Bevan and Hood (2006) refer to “synecdoche” a word whose ancient Greek etymology, signifies that an appreciation of parts is being substituted for an appreciation of the complex whole. Synecdoche opens up opportunities for “gaming”: the deliberate engineering of acceptable statistics in the face of overall poor service quality. Aspects of performance for which good measures exist are thrown into focus and divert attention from those aspects in focus for which no good measures exist and from those aspects not yet brought into focus. Bevan and Hood identify three forms of gaming: ratchet effects, threshold effects and output distortions. Ratchet effects anticipate demands for better performance in the next cycle by limiting performance in this cycle. Threshold effects refer to the relaxation of effort that allows performance to cluster just above the target level. Output distortions occur when standards are met at the cost of less visible aspects of quality. The four hour target has been susceptible both to threshold effects (Mason et al., 2012) and output distortions.

The Keogh review has been guilty of synecdoche because, in its detailed investigation of the mortality performance and internal workings of certain individual hospitals, it has not investigated the planning, governance structures, leadership and network developments which ought to exist in the health economies surrounding the “failing” hospitals and it has not investigated the ways in which to rectify defects in the provision of surrounding services which limit the ability of hospitals to fulfil their role to the highest standards.

Nevertheless, Hakin’s recovery and improvement plan could help to address the mismatch between demand and capacity and patient flow in A&E departments. It has the potential to stimulate the bodies responsible to commission health and social care services to alleviate the pressures A&E departments face, resulting from the lack of a primary care, social care and mental health safety net. Such a safety net could help eliminate bed blocking by elderly, socially dependent patients: if we knew which and how many elderly patients were blocking beds and why they were not already somewhere else. Such patients need safe, well-informed and diligent supervision beyond the emergency department and this is currently not well-supported in every community setting. Stronger mental health and addiction services, better aligned with patterns of demand, could limit the need for patients with problems stemming from alcohol and substance misuse, self-harm and mental ill-health to spend long times in the emergency department or occupy hospital beds. Such arrangements need the commitment of funders, planners and practitioners from various origins, to devise forms of service which bridge the divide between the various elements of urgent care: the 24 hour emergency department, the medical admissions ward, the clinical decisions unit and observation ward, the collocated Out of Hours GP-based care unit and the current, limited-access model of primary care provided by the patient’s own designated GP.

Under the Hakin plan, local Urgent Care Boards will advise and influence the bodies charged with commissioning hospital, primary care and social services, to “ensure that all appropriate services are in place and they hold each provider to account for playing their part”. Commissioners’ new power, to levy a fine on any hospital where patients wait for admission on a trolley for 12 hours, makes no discrimination between a totally unacceptable insult occasioned to that patient by indolent hospital process management, and one caused by genuine capacity restriction, resource starvation and untrammelled demand.

Local recovery plans will “look at each step in the patient’s journey through the emergency system in three phases: firstly, prior to arrival at A&E; second, the patient’s journey through the hospital system; and thirdly, the discharge and out of hospital care”. It is not made explicit that responses to system gridlock and emergency department overcrowding need to be planned, implemented and evaluated jointly, consensually and on equal terms, between partners from planning and all the relevant clinical practice backgrounds.

These responses, to date, have included triage and diversion arrangements, intended to limit demands on emergency departments and individual GPs, and to shield the latter from exposure to work beyond their competence. In the absence of an equally safe alternative, the default position has been for the system to direct the patient to A&E. Hospital emergency departments provide a safety net for primary care but the reciprocal arrangement requires development.

Other responses have been to up-skill non-medical staff and intensify activity within the emergency department but these departments have suffered from shortfalls in medical and nursing complements and problems with recruitment, coinciding recently with a period of national austerity and institutional demands for challenging cost-savings. The collocation of Out of Hours GP and hospital emergency departments in Urgent Care Centres ought to have facilitated the appropriate transfer of responsibility for each patient, from hospital to primary care but there is no universal model of an Urgent Care Centre and standards for such transfer have not been developed. New arrangements at the interface between the emergency department and the hospital have included clinical decision units, where patients’ risk is evaluated systematically prior to discharge without hospital admission, and acute medical admissions units, where patients receive close medical supervision during the first 24-48 hours of their illness. Unfortunately, these units suffer from congestion, high intensity of workload, restrictions on the availability of beds on downstream wards and restrictions on the provision of services for supported care at home.

Knowledge that NHS England is driving the four hour target with renewed vigour is unlikely to reassure the families of patients whose care was compromised by enthusiasm for premature transfer from A&E to somewhere else. Neither will they be impressed by partisan political squabbles over under which party’s regime compliance with the four hour target was better. They need to see that local health economies are applying the optimum governance model applied to the optimal configuration of the resources available locally.

In the UK, the College of Emergency Medicine (2013) has presented key recommendations under ten headings (workload and closer engagement between commissioners and clinicians; service configuration; medical staffing; nursing staff and skill mix; clinical quality indicators of care; network commissioning; observation medicine and ambulatory emergency care; tariffs and informatics systems; and responsiveness to patients’ experiences).

IFEM (2012) and the Australasian College for Emergency Medicine (2007) have already published their quality frameworks elsewhere. The Australasian Emergency Department Quality Framework (Australasian College for Emergency Medicine, 2007) proposes that each emergency department should have five profiles (clinical, educational and training, research, administrative and professional) to reflect its governance structure

The IFEM framework presents nine quality dimensions for the ED (facilities; staff complement and skill mix; physical structure of the ED; culture of quality; data support adequate; effective approach to access block; evidence-based clinical methods and practices; patient experience fed back and acted upon; staff experience fed back and acted upon.

Each of these items is supported in the framework, as suggested by Cameron et al. (2011), by specific quality questions (“measures”) at the levels of structures, processes and outcomes, to indicate whether high quality care is being enabled or hindered.

A concentration on the problems of the UK health service may seem inappropriate in this “international” journal. However, the discussion presented here highlights the complexity of coordination and control in the sophisticated but fallible healthcare system of a non-third world nation. It emphasises the whole nexus of urgent care provision and argues the case to consider carefully in conscious re-design of the local healthcare system, the factors operating outside the emergency department which militate against its achieving compliance with a solitary performance measure. The performance of the emergency department against a four hour national standard may be regarded as a “barometer” (possibly a sphygmomanometer) for the configuration and the deployment of resources within the local healthcare system, seen as a potentially more coherent whole.

The poor performance of an emergency department against this standard may be a symptom of a more widespread malaise affecting the local system as a whole, requiring reappraisal of systemic relationships rather than intensification of activity and entropy. If the recovery plan is operated intelligently, penalties and sanctions for poor compliance will engender a concerted effort throughout the local health and social care system to review and revise decisively the dysfunctional operational and planning relationships which have allowed gridlock, stagnation and demoralisation to develop. Where clinical governance has sought to create “an environment in which excellence in clinical care will flourish” (Scally and Donaldson, 1998) the “environment” has been a cultural, regulatory and procedural one. Concerted efforts are now needed, to create the physical environments and meta-organisational, collaborative structures necessary to promote this flourishing.

Congested emergency departments are by no means an isolated UK phenomenon. Efforts to improve quality are impeded by the impact of congestion and stagnation elsewhere in the systems of hospital and primary and social care. In our international journal, we will welcome future papers describing initiatives which have achieved significant and sustained success in mitigating and eradicating the factors inimical to excellent service quality in hospital emergency departments anywhere in the world.

Nick Harrop

References

Australasian College for Emergency Medicine (2007), Policy on a Quality Framework for Emergency Departments, Australasian College for Emergency Medicine, West Melbourne

Bevan, G. and Hood, C. (2006), “What’s measured is what matters: targets and gaming in the English public health care system”, Public administration, Vol. 84 No. 3, pp. 517–538

Cameron, P.A., Schull, M.J. and Cooke, M.W. (2011), “A framework for measuring quality in the emergency department”, Emergency Medicine Journal, Vol. 28 No. 9, pp. 735–740

College of Emergency Medicine (2013), The Drive for Quality: How to Achieve Safe, Sustainable Care in our Emergency Departments, College of Emergency Medicine, London

Cooke, M.W. (2013), “Intelligent use of indicators and targets to improve emergency care”, Emergency Medicine Journal, published online 12 February 2013, available at: www2.warwick.ac.uk/fac/med/research/hscience/sssh/publications/intelligent.pdf

Francis, R. (2010), Investigation into Mid Staffordshire NHS Foundation Trust March 2009, The Healthcare Commission, UK, ISBN: 978-1-84562-220-6

Hakin, B. (2013a), “Delivery of the A&E four hour operational standard”, available at: www.england.nhs.uk/wp-content/uploads/2013/05/ae-letter.pdf (accessed 16 July, 2013)

Hakin, B. (2013b), “NHS England: Improving A&E Performance: Gateway ref:00062”, available at: www.england.nhs.uk/wp-content/uploads/2013/05/ae-imp-plan.pdf (accessed 16 July, 2013)

Hughes, G. (2012), “A&E quality indicators”, Emergency Medicine Journal, Vol. 29 No. 2, p. 90

International Federation for Emergency Medicine (2012), “Framework for quality and safety in the emergency department”, available at: www.ifem.cc/Resources/PoliciesandGuidelines.aspx (accessed 16 July, 2013)

Lansley, A. (2010), Open letter to John Heyworth, President of the College of Emergency Medicine: POC1514487

Mason, S., Weber, E.J., Coster, J., Freeman, J. and Locker, T. (2012), “Time patients spend in the emergency department: England’s 4-hour rule – a case of hitting the target but missing the point?”, Annals of Emergency Medicine;, Vol. 59 No. 5, pp. 341–349

Scally, G. and Donaldson, L.J. (1998), “Clinical governance and the drive for quality improvement in the new NHS in England”, BMJ, Vol. 317 No. 7150, p. 61-65

Further Reading

Hughes, G. (2013), “Mid-Staffordshire the final report”, Emergency Medical Journal, Vol. 30 No. 6, p. 432