An all too familiar story has dominated the headlines in recent weeks.  Queues are mounting up at Accident and Emergency Departments across the country.  Apparently A&E performance is now at its worst for 10 years, with hospitals missing their target that 95% of patients are seen within 4 hours.

Labour’s Health spokesman, Andy Burnham, blames the crisis on government cuts, while the Health Secretary, Jeremy Hunt maintains that he has given the NHS the £700m that it asked for to tackle rising demand.  Nick Clegg has responded by pledging an additional £8m for the NHS.   

So, here is my question: is lack of money really the problem here?  Pumping in more money doesn't seem to have had the desired effect so far.    

It was Albert Einstein who famously quipped that you can't do the same thing in the same way and expect different results.  Yet this is exactly what all three parties seem to be doing. 

There is one other potential cause of the A&E crisis which rarely gets a mention… that of the target itself.

It seems to me that there is a real attribution problem here.  The fact that so many A&E departments are falling behind on their targets shows that there are factors at play which are beyond the scope of an individual A&E unit to influence.  A&Es are part of a bigger system. 

Faced with a penalty for something that is outside of your control, how would you respond?

Gaming of targets in the NHS is clearly endemic - there are countless tales of patients waiting longer in ambulances so that the 4 hour wait is not breached.  One A&E Doctor told me that if he has a patient who he feels needs urgent support, and another patient is about to go over the 4 hour target waiting limit but who needs less urgent support, the hospital tells him to prioritise the second patient.  But once someone passes the 4 hour marker they could be waiting there for hours - the actual length of time they have to wait is not captured in the figures.  Indeed, when my own mum went to A&E she was asked to leave and come back in again so that they would not breach their target. 

What we need to be doing is working out why more people are coming into A&E and using this learning to redesign the health and social care system as a whole. 

A lot of the demand in A&E is a result of failures in the system earlier on.  Referrals to A&E from 111 call centres have risen markedly.  111 call centres are staffed by low-skilled and low-paid staff, who follow computer scripts and have a target for whether they pick up the phone within 60 seconds.  So naturally, this is what staff focus on, rather than how they can best advise the person on the line.  No wonder they have high staff turnover figures.

What should be done

Health and social care staff should be allowed to get on with their job: helping people get well as soon as possible.  With this as their purpose, they don't need targets.  In fact, removing the targets would probably (and paradoxically) result in lower waiting times and save the NHS money at the same time. 

The government's attempts to integrate health and social care demonstrate some appreciation of the need to see these services as a whole.  But they're planning more targets (the Better Care Fund will be conditional on A&E waiting times reducing year on year). 

A better measure would be how long it takes to resolve someone's health issue from start to finish, across the whole health and social care system, not just the time they're waiting in A&E. Then the real reasons for any delays can be identified and ironed out, and staff would be incentivised to do the right thing for patients rather than merely meet/game their department's target.

At the Glasgow Autumn Conference in 2014, Lib Dems voted in favour of targets that should be used "with extreme caution" in public services. Ministers would do well to take this on board.

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  • Thanks for your comments Simon and Gareth. You’ve both raised some good points. Yes, measures are important, but targets are only one type of measure. It is possible to use measures in a mature way at a local level with the aim of learning where there is scope for improvement in a service, rather than to make senior people feel comfortable about what is going on (“feeding the machine”) which is the ‘de facto’ purpose of targets.

    For more on this, see this excellent blog piece:
  • My recent experience of 111 was excellent – a guy who sounded concerned but was businesslike. He can’t have been following a pre-set script and if he was feeding answers into a computer which suggested more questions, that’s fine. I ended getting an out of hours appointment for later that day, which was appropriate. His questions had systematically eliminated more serious causes than what it turned out to be (inner ear infection with loss of balance).

    There are certainly big problems with A&E: some come from targets, but the issue is not so much the setting of targets and the taking of measurements (which after all rang the bell for the problems at Mid-Staffordshire) but their interpretation and unintelligent use for sticks and carrots. More GP availability would certainly help (some waits are unacceptable) but that means spending more on training and placing GPs. Where independent GPs don’t want to go, let their be employed GPs paid a wage. And the most cost-effective solutions are in healthier living, but you never get a media headline “MOTHER DIES TWENTY YEARS AFTER FAILING TO GIVE UP SMOKING”.
  • Fair comments on the targets causing peverse results, but is it that targets ‘full stop’ are wrong or more that the metric being measured is wrong?

    Without any form of data gathering or targets it would be impossible to work out if things are improving or getting worse, or the benefits of certain initiatives