Opinion: Time to dump the 4 hour A & E target

To be frank, as a doctor, I have been underwhelmed by our Liberal Democrat offering on health issues over the years; certainly we are not as strong on health as we should be.

The almost daily drip feed from the right wing press on NHS shortcomings and failures is demoralising to staff and frightening to patients and designed to be so. It serves no-one except those who want to undermine the public’s confidence in the NHS. The service treats three quarters of a million patients every day of the year, and for most people there is no alternative.

So I am  relieved that at last we have something distinctive to offer with Norman Lamb’s ideas on mental health; parity of access and delivery, more  research and funding. This is important, and we need to ‘own’ it as Liberal Democrat policy.

Mental health is a bit like cancer in that it touches every family at some point, but no one wants to talk about it or admit they might get it. One in four of us will suffer directly and all of us know someone in our family or circle of friends who has had, or is suffering depression, or psychosis. Quite a lot of us will know someone who has attempted suicide, or even succeeded.

The need to tackle suicide specifically is long overdue and important, but don’t let’s fall into the trap of having a zero suicide target. This is unachievable and will be yet another failure to beat the health service with.  Instead, I hope we can settle for steady downward pressure, year on year, on the numbers of attempted and completed suicides and celebrate each year what has been achieved.

However, we clearly need to offer more on health so here is my idea for a no cost policy which will grab headlines AND be very welcome to all hard pressed NHS staff.

Dump the 4 hour A&E target.

This ill-conceived target helps no-one, neither patients nor staff, and is universally hated by staff because it distorts the work flow on the basis of need. As the clock ticks towards the 4th hour patients are juggled around and given priority their condition does not deserve in a desperate attempt to avoid the inevitable ‘breach’ and newspaper headline.

In a big, busy A&E (and with the current reconfiguration there will be no other kind of A&E) only the simplest casualties can make it through the system in this timeframe. Yes, you may be able to get a cut finger stitched, have your tetanus booster and be out of the door in four hours, even if you have to wait a while to be seen because there are other patients in the queue before you, the reality of any public system, but sadly most A&E patients have more complex needs.

This 4 hour target is not about everyone being seen within 4 hours. That’s relatively easy. It requires assessment, diagnosis, treatment and discharge within that time frame. First you’ll be seen and  investigated with whatever tests are needed, such as X-rays, scans or blood tests. To have these done, you will need to go to other parts of the hospital and sit in other queues. You might even have to see a specialist. You then have your test results analysed, receive the  appropriate diagnosis and  treatment (or none) and are discharged. Achieving all of that in 4 hours is a huge and unnecessary challenge. This target sets up A&E to fail, and guess what, it’s failing. Let’s dump it and get on with treating patients according to their needs, and if it takes 6 or 8 or even 12 hours, so be it. The important thing is that each patient gets the time and attention they need. That’s an equitable service.

* Catherine Royce was previously PPC for Uxbridge (2001) and Romsey (2017) as well as being on the Liberal Democrat Women executive. She is currently a member of the Federal Policy Committee and the Liberal International British Group Executive.

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  • Simon McGrath 29th Jan '15 - 4:37pm

    “The almost daily drip feed from the right wing press on NHS shortcomings and failures is demoralising to staff ”

    Did you miss the daily drip feed from Labour about how the NHS has been ruined by the Coalition ?

  • Amazing article. In a properly run NHS the managers of any A&E department would be fired if anyone had to wait anything like four hours.

  • A Social Liberal 29th Jan '15 - 8:00pm

    After the coalition came into power the targets were lowered and STILL A&Es were unable to make them.

    It isn’t that the quality has gone down, it is that numbers going to A&E are rising whilst the numbers staffing emergency departments is going down, as are major A&E departments themselves. Top tip – don’t close A&Es and numbers seen in time won’t drop, staff A&Es with the numbers of staff needed and the targets will be realised.

    I do find it funny though that every time the Tories get power state education start suffering, state health institutions likewise become sub standard whilst the numbers of public servants drop to a point which is alarming !

  • Stephen Donnelly 29th Jan '15 - 8:51pm

    Chris, I presume by properly run, you meant properly managed, with a minimum of political interference, and adequate funding.

    Simon, all the political parties are being dishonest about the health service because the present model is not sustainable. The Conservatives had admitted the Lansley reforms were a huge mistake. We have yet to do so. Criticisms of the coalition are valid but Labour do not have any answers.

  • I’m not sure what this big focus on mental health will mean. Having some experience in this area I’m not sure if many successful mental health treatments have yet been identified. Perhaps for things like psychosis but the most common mental illness is depression. I’m not sure the evidence for effectiveness of depression treatments, be it medication or counselling, is very strong. Perhaps the best thing would be to focus on sociocultural factors (not really NHS) in particular promoting positive mental health amongst children.

  • It is obvious that the rightwing press are drip-feeding nonsense about the NHS .
    As Dr Royce says in her article —
    ” It serves no-one except those who want to undermine the public’s confidence in the NHS.”

    There are plenty of lobbyists and private healthcare giants who are determined to undermine the NHS.
    They see rich pickings available from breaking up the NHS.

    Setting up the NHS to fail by setting meaningless and unachievable targets is the first step to privatisation.

  • I agree with Chris. The other, linked, scandal is waiting times to see a GP, especially before 0900 or after 1700! Overcosseted GPs need to enter the modern era….

  • The target was needed initially. I have vivid recollections of my mother’s long waits in corridors. And i was pushy daughter and local Cllr and onetime NHS worker. But I do think the meaningful wait is between arrival and triage. And that may vary a bit if there is a majore accident.
    The perverse effect is that wait for GP equals a day or two and for A &E four hours…and they wonder about the extra workload.
    I wish the Party would talk about Rehab between Hospital and home. Too early discharge brings patient back!

  • Simon McGrath 30th Jan '15 - 12:00pm

    @John Tilley “It is obvious that the rightwing press are drip-feeding nonsense about the NHS .
    As Dr Royce says in her article —
    ” It serves no-one except those who want to undermine the public’s confidence in the NHS.”

    It must be a great comfort to the relatives of those patients who died in the mid Staffs hospital scandal to know that it was all a right wing plot.

  • Great article – so important to talk about the 4-hour A&E target which, if it applied too rigidly, is clearly putting unnecessary pressure on hospital staff and distorting the priority with which patients are seen. (A similar scenario applies to the distortion caused by school league tables based on exam results). As long as life-threatening and serious cases are seen and assessed within 4 hours, what does it matter if other people have to wait a bit longer? And to say NHS A&E services are in trouble because the 4-hour target has been missed by a few percentage points seems like statistical scaremongering. The fact that 92.6% of patients were seen within 4 hours (in England) according to the the latest figures is brilliant.

    On the other issue discussed in the article, parity of esteem for mental health is of course vital, but I think the Lib Dems may need to present more of a comprehensive approach to health policy to be really heard. We need to say more about prevention of illness (which could save billions), managing long-term conditions, improved care in the community for those coming out of hospital ((the number of district nurses has almost halved to around 6,000 in the last ten years) and using new health technologies to save money.

    The ‘new’ GP contract of 2004 with its emphasis on testing and diagnosis tied to pay and performance may also have had something to do with the rapid escalation of costs in the NHS over the past decade.

  • Neil Sandison 31st Jan '15 - 9:57am

    What a sensable contribution by Catherine The black propaganda from both the extream wings of politics is not congratulating the hospitals and Trusts who are doing a fantastic job or supporting and improving those units that are struggling through local problems to acheive their targets .I have not been impressed by the decentralisation of hospital services into countrys and regions perhaps it is time to return to a United Kingdom NHS so that the customers ie the patents get the best service possable within the resources available regardless of where they live.If that was the case then the public would have less to critisise if we asked for additional funding through the general tax system to support health and social care provision.

  • Andrew Tennant 31st Jan '15 - 7:12pm

    If the majority of people have no alternative to enduring more than a four hour wait to receive adequate medical treatment, then we need to reform the way services are delivered sufficiently to offer them one.

    Having had the displeasure of experiencing our ‘treasured’ NHS more than I would care to since my son was born, then I’ve been hugely disappointed by the bureaucracy and inefficiency that is apparent on each visit, the difficulty in accessing a competent and local medical practitioner, and the lack of customer focus/patient care that staff seem inclined to provide.

    If NHS staff are capable of raising standards from where they are then they should be vocal about how and get on with it. If they can’t then I’ll be growing increasingly impatient for greater competition and the chance to choose something better.

  • John Broggio 31st Jan '15 - 8:05pm

    Andrew, the reason you can’t vote with your wallet at the moment in paediatrics is because almost no private healthcare provider is prepared to touch it: too risky, too complex.

    Also, even though the US (with all their wonderful “choice” & “competition”) spends almost double the amount of GDP that we do (17.7% vs 9.4% in 2012 – http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS) , their life expectancy is lower than ours (79y at birth vs 82y at birth – http://data.worldbank.org/indicator/SP.DYN.LE00.IN)…

  • suzanne fletcher 31st Jan '15 - 8:17pm

    I agree with the comments about the targets. I had the misfortune to need the service at one of the worst possible times – the saturday night between christmas and new year when everywhere froze over. I’d had a new knee 10 days before and my leg froze completely and then went into very painful spasms. I literally could not move at all. 6 hour wait for ambulance (just no way I could have got to or into a car). 4 and quarter hours in A and E extremely uncomfortable. How I would have loved to have been on a trolley so some support for my leg, but no sign of one, and I had no idea how long i had to wait. there was nothing to prop my leg up on whilst I was in a wheelchair – the sick bowl offered to use upside down was too high, and my husband had to pack our coats under my foot, and keep adjusting as it slipped. contradictory advice all night from ambulance people about whether I could drink and I was badly dehydrated. when i was finally put onto a trolley nothing to prop my bent knee with (lucky I had hubby with me to arrange his mac under it). eventually, after 14 hours since it began the knee began to straighten on its own, helped by being on the bed.
    what would have made a difference would have been able to be at home till nearly time to have been seen when at least I was more comfortable with more things to prop the leg with (I can see that might not have been possible); something to make me comfortable whilst waiting ( it wasn’t nice for others when I was involuntarily screaming out) and I could have then waited longer. consistent advice on such as drinking, and information that there was a disabled toilet my husband could accompany me to.
    they were worried about a blood clot in the joint or infection, but in retrospect (easy) if we could have been e-mailed a prescription for diazapam to ease the spasm, husband could have gone and got it from an all night chemist and that would have sorted it. i went home with 5 of them, bliss !
    it would have also helped if they could have had my notes from the hospital that did the op. but it was a private hospital who did such ops under an NHS contract, and they were not allowed to access blood tests, xrays or anything else. similarly the private hospital could not access what tests were done at the NHS hospital whilst in A and E. very lucky for me the consultant is at both, and he managed to see both.
    A long story there, but I do wonder if there is ever a chance to put your views as to what little things would have helped. the target is most irrelevant thing.
    final straw was Jeremy Kyle blasting out on the TV. when it finished the dead looking lad in a wheelchair next to me and his dad walked out when it finished !

  • @Andrew

    It’s really regrettable that you have had a bad experience with the NHS, but I have to say our local GP service is excellent (I always manage to get an appointment on the day) and that goes for our out-of-hours and local A&E service too which I have had to use a couple of times over the past six months. Test results now come back within days, as opposed to the weeks it took years ago, and patients are consulted more about their treatment rather than the ‘we know what’s best for you’ attitude prevalent decades ago. Yes, there are terrible exceptions like Mid Staffs, but I think painting such a bleak picture does not reflect the really great work done by so many of our NHS health professionals.

  • Simon McGrath 30th Jan ’15 – 12:00pm

    Simon McGrath, I am not sure if you actually know any of “the relatives of those patients who died in the mid Staffs hospital scandal ” or what relevance they have to any comment of mine.

    Perhaps you did not think it through before you made your gratuitous reference.?
    Or perhaps you regard your defence of the vested interests of rightwing press barons as more important?

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