Focus on targets in NHS poses threat to patient care, says thinktank

http://www.theguardian.com/society/2015/mar/06/focus-targets-threat-care-nhs-patients-thinktank

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A “targets and terror” approach to ensure large hospital A&E departments in England treat, admit or discharge 95% of patients within four hours may undermine their care, a former senior NHS official has said.

The micro-management culture within the NHS and Department of Health coupled with increasingly tight budgets will hasten the point at which entire urgent care system reaches breaking point, says Nigel Edwards, chief executive of the Nuffield Trust thinktank.

Senior managers in hospitals are so busy collecting information on how they are doing each week to satisfy regulators, NHS bosses, health commissioners and politicians that they are not sorting problems on their own frontline, Edwards and two co-authors claim in a briefing paper.

Major A&Es have not hit the 95% mark since summer 2013 despite all the attention paid to weekly figures in recent months, they say.

But emphasis on the four-hour measure distorts the picture of how big hospitals are doing in the face of a 12% increase in attendances at their A&E units and a 27% increase in emergency admissions in a decade.

The A&E rise is “entirely in line with what would be expected based on population growth”, according to the paper, which warns that 17,000 extra hospital beds could be needed by 2022 unless more could be done to treat people outside hospital.

The NHS response was based “on the anxiety of the hierarchy rather than on the care of patients and the flow of patients through the system”, it said.

Edwards, a former policy director at the NHS Confederation, which represents health service leaders, said the four-hour target had come “to loom over every other measure” in monitoring emergency care.

“Politicians and regulators need to stop micro-managing this target and should instead examine how to put the four-hour target on an equal footing with other critical indicators like trolley wait or time to treatment.”

The paper also questions whether A&E problems are down to changes in family doctor contracts in 2014 making it harder to see GPs out of hours, difficulties in getting GP appointments, patients misusing the system, or poor triaging by the NHS 111 service.

In a separate article for the Health Service Journal, which is read by healthcare leaders, Edwards said trust research found “site managers who should be spending their first hours at work checking on the hospital were frequently diverted by the need to gather information and to participate in conference calls”.

“Paradoxically, the point at which things become most fraught – for example, when a hospital runs out of beds – is exactly the point when the demand for information, actions and progress chasing becomes most intrusive,” said Edwards.

The “blame-engineering” ritual “gives comfort to people who are fielding demands for action and assurance from above but, in fact, have no real control over the situation and, even if they did, might not have the expertise to use it.”

Jeremy Hunt, the health secretary, was last year accused of being a control freak by unnamed NHS bosses and neither of this week’s interventions by Edwards names critics within the NHS.

His remarks follow claims from senior clinicians that less than 1% of the extra £700m allocated for emergency care in England this winter ended up directly in A&E departments. They were strongly denied by NHS England and the Department of Health.

In response to the Nuffield paper, the department said: “The A&E target is an important part of making sure patients get seen quickly and safely, with over nine out of ten currently being seen, treated or discharged in 4 hours. Patients would expect the health secretary and senior NHS leaders to pay close attention to quality of care.”