The government has recently suggested that the four-hour waiting time target, a pledge set out in the Handbook to the NHS Constitution, will be scrapped. Despite some positive statistics with the policy, recent comments from the Health Secretary Matt Hancock suggest a change after an ongoing review into NHS clinical targets. This review has released an interim report suggesting that there will be four areas of focus for the new target: the time to initial clinical assessment, the time to emergency treatment for severe patients, the mean waiting time target calculated across all patients, and the utilisation of ‘Same Day Emergency Care’ to avoid overnight admissions.
Specifically, Mr Hancock, told BBC Radio 5 Live, assumingly after the NHS received its worst waiting times this winter since the target began in 2004, that ministers should be judged by “the right target” and a “clinically appropriate” one was needed. Currently, the proportion of patients attending major A&E departments in England that were seen within four hours has been at its lowest ever, having only managed to treat and then admit, transfer or discharge 68.6% of arrivals, far below the 95% that minsters say should be dealt with.
But, is it really that bad? Recent data involved with the distribution of A&E waiting times in 2011-12 and 2012-13, showed that during a period where hospitals were meeting targets for all patients in major NHS hospitals, that waiting times spiked before the four hours, with more than 10% of patients being admitted discharged or transferred to another hospital in the final 10 minutes before reaching the target. This, in contrast, creates a sharp decline after the four hours and is estimated that the target reduced waiting times by approximately 20 minutes.
Significantly the target has led to other benefits and impacts for the NHS, such as a 12% increase in the number of inpatient admissions as well as the extra visits increasing the average patient cost by £95, a 5% increase on an average cost of around £1,900.
Patients also have benefited from the policy by managing to reduce 30-day patient mortality by 14%, but with this in mind, it begs the question as to what is saving these lives – lower waiting times or extra admissions? A working paper from the IFS (Institute for Fiscal Studies) reveals that whilst there is no relationship between admissions and deaths, there are some that suggest that it is the bigger reductions in wait times that are associated with the larger mortality.
But what does this all mean for the proposed changes to the target? It’s fair to say that the four-hour target has played a pivotal role in improving A&E care since it was introduced. However, in light of recent performances over the past winter, no way does this mean that the NHS care can’t be better, the recent delays and compromises of service evidence this, but for every change they make or every scheme they draft, there needs to be a thorough thought process going into the design of any alternative targets introduced.
The benefits of the current target, in terms of mortality, are mainly a result of them being time-sensitive patients, many of which will also be included in the list of priority patients, therefore focusing the attention on these patients (including conditions such as sepsis, heart attack and stroke) could perhaps achieve even greater reductions in mortality than realised under the current policy. With that said, there is still little evidence for what the ‘right’ target time would look like to maximise the patient outcomes as well as one that would be acceptable for them. The one thing that will be guaranteed is that it will be highly disputed as we wait among further details to emerge.
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