NHS targets

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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 were 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 hospital care and A&E performance measures for October 2019 were the worst ever recorded.[4]

Around the UK[edit]

The NHS Constitution for England specifies waiting times in the accompanying Handbook, but does not provide a remedy should they be breached. The Patient Rights (Scotland) Act 2011 establishes the treatment time guarantee, but also does not specify a remedy should it not be met.[5]

Targets in Northern Ireland are set by the Health and Social Care Board and are less demanding than in the rest of the UK. None have been met since 2015, and some for considerably longer.[6]

Accident and emergency departments[edit]

Percent of patients in English A&E departments waiting over 4 hours, monthly, 2011-2018

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.[7] 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.[8] 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.[9] In January 2017 Jeremy Hunt announced that the target would in future only apply to "urgent health problems".[10] 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.[11] In December 2018 it was reported that patients with only minor ailments could be excluded from the target and a new target introduced so the most urgent cases should be seen within an hour.[12]

The effect of the target can be that patients waiting just below 4 hours get a lot of attention, but once the target is breached there is no further consequence. The average time spent by a patient in A&E who has breached four hours is around eight hours.[13]

Objective[edit]

The Labour government (1997-2010) 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".[14]

48% of departments said they did not meet the target for the period ending 31 December 2004.[15] 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.[16]

The four-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-labelling 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.[17]

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.[18] The announcement of the reduction of the target from 98% to 95% was immediately followed by a reduction in attainment to the lower level.[19]

Performance[edit]

A&E Attendances

By December 2014, the number of patients being treated within four hours had fallen to 91.8%.[20] From December 2015, the 95% target over England as a whole was missed every month. From October-December 2016, only 4 out of 139 hospitals with major type 1 A&E departments met the target.[21] In November 2018, the British Medical Association reported that performance on emergency admissions, trolley waits for more than four hours and A&E patients seen within four hours in the summer of 2017 was worse than in the winters of 2011-15.[22] Performance against the four-hour wait target in the summer of 2018 was the worst second quarter performance recorded. Only 88.9% of patients were seen within four hours in September. The number of people admitted, transferred or discharged within four hours in emergency departments in September was up more than 3% compared to September 2017 with a 7% rise in emergency admissions said by John Appleby to be astonishing.[23] Attendance at A&E departments has been increasingly steadily for many years, more so at ‘type 3’ departments, like urgent care centres (where waiting times are generally lower). In the first eight months of 2018, an average of 67,000 people attended each day.[24] In January 2019, only 84.4% of patients were seen within four hours, the worst figure since the target was introduced in 2004.[25]

Performance in the first three months of 2019-20 was the worst since records began in 2011.[26]

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.[27]

In Northern Ireland, performance is much worse. In 2012, only 77.2% of patients were seen within four hours, but by 2016-17; this had dropped to 75%. Attendances had increased by 13%.[28] In 2014-15, 3,170 people waited over twelve hours for emergency care and by 2016-17; this had increased further by 105% to 6,494 people.[29]

Missing the target[edit]

According to the BMA[15] 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.[30]

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.[31]

Pressure[edit]

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.[14]

Twelve hour target[edit]

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. In England the time is measured from the point a decision to admit is made and not from the moment the patient arrives. 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.[32] 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.[11] Problems at Lancashire Care NHS Foundation Trust led to more than 1,000 cases of patients waiting over 12 hours for admission in 2018-19. This was about a third of all the 12 hour breaches, which were mostly mental health cases - where admission to a ward is not within the control of the trust running the A&E department. A review found that some patients in Lancashire were “potentially being held against their will without appropriate legal provision”. Some were detained in seclusion rooms for more than a week under section 136 of the Mental Health Act 1983, which only provides that patients can be lawfully detained for 24 hours, with a possible 12-hour extension.[33]

Cancer[edit]

All across the UK the target is that patients should be treated within 62 days of an urgent referral, but the way this is measured varies.[34] In Northern Ireland the target has not been met since 2015.[35] In England 93% of patients referred for investigation of breast symptoms, even if cancer is not initially suspected, should be seen by a specialist within two weeks.[36]

Only 38% of hospitals met the target in 2019 and 22.5% of people waited longer than two months for their first treatment.[37]

Planned treatment[edit]

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.[38] 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. The proportion of people waiting more than the six week target for diagnostic tests was at its highest since records began in September 2018.[23] By August 2019 less than 49% of hospital services were achieving the target and across England the average wait was around 23 weeks.[39]

One year wait[edit]

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.[40] 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.[41] 2,432 patients had waited longer than a year in November 2018. In January 2019 NHS England announced that in future both providers and commissioners would be fined £2,500 for each such patient.[42]

In Northern Ireland more than a third of patients, 94,222 people, had waited more than a year for their first appointment in October 2018. According to the Royal College of Surgeons in Ireland the 52-week target had "not been completely achieved in over 11 years".[43]

Six month wait[edit]

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.[44]

Cancellations[edit]

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.[45]

See also[edit]

References[edit]

  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. ^ "Hospital waiting times at worst-ever level". BBC. 14 November 2019. Retrieved 14 November 2019.
  5. ^ "'The NHS paid for my new French hip'". BBC. 3 December 2018. Retrieved 4 December 2018.
  6. ^ "Northern Ireland NHS 'simply unable to cope with the demands placed on it': report". Belfast Telegraph. 18 December 2018. Retrieved 20 December 2018.
  7. ^ The Four Hour Target in Accident and Emergency
  8. ^ https://www.theguardian.com/society/2013/apr/02/nhs-four-hour-targets-aande
  9. ^ "Third of providers will still miss A&E target in March 2017". Health Service Journal. 21 July 2016. Retrieved 19 March 2017.
  10. ^ "Jeremy Hunt ditches four-hour target as A&E crisis deepens". Guardian. 9 January 2017. Retrieved 19 March 2017.
  11. ^ a b "Trolley waits soar to record high". Health Service Journal. 8 February 2018. Retrieved 2 April 2018.
  12. ^ "NHS chiefs look to scrap four-hour A&E maximum wait". Guardian. 2 December 2018. Retrieved 2 December 2018.
  13. ^ "Performance Watch: A sneak preview of a keenly awaited review of A&Es". Health Service Journal. 22 May 2019. Retrieved 8 July 2019.
  14. ^ a b BBC NEWS | Health | Target 'putting A&E care at risk'
  15. ^ a b BMA - BMA survey of accident and emergency waiting times, March 2005
  16. ^ BBC NEWS | Health | A&E success 'not sustainable'
  17. ^ 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.
  18. ^ Blunt, Ian. "Why are people waiting longer in A&E?". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 2 February 2015.
  19. ^ 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.
  20. ^ "Indicator: A&E waiting times". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.
  21. ^ "What's going on in A&E? The key questions answered". King's Fund. 6 March 2017. Retrieved 19 March 2017.
  22. ^ "NHS emergency care in crisis all year round". Sky News. 7 November 2018. Retrieved 13 November 2018.
  23. ^ a b "A&Es miss national objective with record low performance". Health Service Journal. 11 October 2018. Retrieved 13 November 2018.
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  27. ^ "SNP attacked over year of missed NHS targets". Scottish Express. 29 July 2018. Retrieved 14 August 2018.
  28. ^ "Four NI health trusts among worst performers for ED waiting times". BBC. 7 December 2017. Retrieved 20 December 2018.
  29. ^ "Northern Ireland NHS 'simply unable to cope with the demands placed on it': report". Belfast Telegraph. 18 December 2018. Retrieved 20 December 2018.
  30. ^ Blunt, Ian. "Focus on: A&E attendances". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.
  31. ^ "NHS needs 5,000 more beds, warn leading A&E doctors". Health Service Journal. 7 July 2017. Retrieved 23 August 2017.
  32. ^ "12-hour patient waits in A&E increase by 10,000% in five years". Healthcare Leader. 25 September 2017. Retrieved 22 December 2017.
  33. ^ "Revealed: Why one county saw a third of all 12-hour A&E breaches". Health Service Journal. 17 May 2019. Retrieved 8 July 2019.
  34. ^ "Check NHS cancer, A&E, ops and mental health targets in your area". BBC. 13 December 2018. Retrieved 20 December 2018.
  35. ^ "Northern Ireland NHS 'simply unable to cope with the demands placed on it': report". Belfast Telegraph. 18 December 2018. Retrieved 20 December 2018.
  36. ^ "Trust hits waiting time target in just 8pc of cases". Health Service Journal. 9 April 2019. Retrieved 17 May 2019.
  37. ^ "Cancer patients forced to wait 'unacceptably' long time for NHS treatment". ITV News. 11 July 2019. Retrieved 12 July 2019.
  38. ^ Patients waiting for planned NHS hospital care top 4m for first time in a decade
  39. ^ "Majority of local services are now breaching 18 weeks". Health Service Journal. 12 September 2019. Retrieved 3 November 2019.
  40. ^ "Year-plus elective waiters at highest number since 2012". Health Service Journal. 8 February 2018. Retrieved 2 April 2018.
  41. ^ "Year-plus waiters rise 75 per cent". Health Service Journal. 31 May 2018. Retrieved 17 August 2018.
  42. ^ "New fines for leaving patients waiting more than a year". Health Service Journal. 10 January 2019. Retrieved 13 February 2019.
  43. ^ "Lengthy waiting time figures are 'deeply distressing'". Irish News. 29 November 2018. Retrieved 20 December 2018.
  44. ^ "Numbers 'going private' for surgery soaring as NHS rationing deepens". Telegraph. 11 August 2018. Retrieved 14 August 2018.
  45. ^ "Last minute cancelled operations hits highest rate since 2005". Health Service Journal. 10 May 2018. Retrieved 13 August 2018.