Editor’s blog Thursday 10 June 2010: The first waiting time target to go: 4-hour A&E “as it currently stands”

During his statement on the new Mid-Staffordshire inquiry, Health Secretary Andrew Lansley CBE MP gave the Black Spot to the 4-hour maximum waiting time target in A&E – with the proviso “as it currently stands”.

It is a fascinating decision, and not one without political and clinical risks.

Clinically, Lansley’s case is that at Mid-Staffs, safety was not the priority. It was undermined by politically motivated process targets” He went on to promise, “We will scrap such process targets and replace them with a new focus on patients’ outcomes”.

Clarifying this in response to Shadow Health Secretary Andy Burnham, Lansley added, “we are therefore going to consider, constructively, how to scrap the four-hour target as it currently exists, and … work on the basis of saying that what the clinical evidence makes clear directly contributes to delivering the best possible results for patients. … Our approach will go beyond the simple question of how long people wait in an emergency department; it will go to the outcomes being achieved in those departments”.

Francis sought extra scope for original inquiry; Burnham refused it
Lansley also revealed to the House that, “Robert Francis came to him (Andy Burnham) in the midst of his first inquiry to raise the issue of the legal base for that inquiry and the question of whether it should be brought under the Inquiries Act. He wanted the terms of reference to be extended sufficiently widely to ensure that at that stage he could have looked beyond the question of what happened, to the question of why the primary care trust, the strategic health authority, the NHS in general, and other organisations, did not intervene earlier and in a better way. On 10 September last year, the then Secretary of State did not agree that that should happen”.

Changes on HSMRs, and focus on nurses’ bureaucracy
Responding to MPs’ questions on the statement, Lansley also stated that “The SMRs are not a sufficient measure of quality across the board”.

He also told new MP Dr Sarah Wollaston GP, who asked “Will the inquiry cover the sheer volume of bureaucratic paperwork that nursing staff have to complete, which seriously gets in the way of their fulfilling their clinical responsibilities?” that the answer was “yes”.

What all this means
Just as there are unintended consequences of having targets, there will be unintended consequences of doing away with them.

The original Francis inquiry did ascribe some blame for Mid-Staffs’ poor and harmful patient care to the fear of missing waiting time targets. Francis wrote, “the pressure to meet the waiting target was sometimes detrimental to good care in A & E.”

Yet by no means all the bad care was in A&E at Mid-Staffs. The principal reason the Trust was understaffed by 120 nurses was to ensure financial balance so that the Trust could succeed in its application to become a foundation trust.

Targets distort priorities: that is what they are there to do. The balance to be achieved is between avoiding putting unacceptable pressure on clinical practice and safety and allowing unreconstructed working methods to put patient experience last. Once again, former deputy CMO Aidan Halligan’s words “working patterns, practices and customs are at the heart of many capacity issues” spring to mind.

Reports by the Primary Care Foundation (COI declaration – with whom I do paid work) into urgent and emergency care strongly correlate prompt care with good care in the urgent and emergency setting.

The 4-hour A&E target was not perfect as it was, and probably required more nuance around streaming A&E majors from minors (not to mention some genuine introduction of ‘see and treat’ approaches). What they did do was compel the NHS to think about patient experience of waiting and act on it.

The comments on HSMRs and nurse bureaucracy raise important issues. Nurses probably do spend too long filling out forms, due to the NHS’s woeful failure to get IT doing much more data collection in real time at the point of care.

Nor are HSMRs perfect measures of care, focusing as they do on deaths, but they do tell us something significant, which should be correlated against other data.

Mid-Staffordshire NHS Foundation Trust was a hard case. The axiom is accurate: hard cases make for bad laws. It wasn’t all about the process targets: it was about money, ambition and power. It was about a sick culture.