Who is the four-hour target for?
The current four-hour A&E performance target has been around for 15 years and is a valuable measure of system-wide performance.
At an operational level it encourages hospitals to keep patients moving through departments, helping to prevent potentially dangerous overcrowding.
At a more strategic level it is a useful indicator for commissioners, regulators, and system commentators of how well hospital trusts are performing.
Yet as we have highlighted before, the target is less good at helping patients understand what to expect when they visit A&E themselves. It tells us little about other aspects of people’s experience, and since performance to the target varies, it doesn’t inform people how long they will actually have to wait.
So while it is well documented that the NHS nationally has not met the four-hour A&E target since 2015, and December 2019 marked the worst performance to date, it is not clear exactly what this means for individual patients.
Time is not the only thing that matters
To have confidence that we understand whether the system is working for patients, it’s important to focus on more than just the length of time people spend in A&E.
Our national polling and interviews we have conducted with patients in A&E indicate that while the length of someone’s visit is important, people are more interested in the overall quality of care on offer at their local hospital.
People tell us that the quality of their experience is shaped by diverse factors including communication, staff attitude, the speed of initial assessment, the facilities within A&E departments and whether people feel other parts of the NHS are working together with the A&E department to provide joined-up care.
Of all of the above factors, communication was raised most frequently, with people stressing that they want to be given reassurance that they are in good hands when they arrive at A&E, to be provided with a rough idea of how long they may have to wait, to be fully involved in any decisions about their care and kept informed if things change.
Different factors interlink to shape people’s overall experience. For example, we heard numerous examples from people who spent a long time in the emergency department but made no comment about the length of their visit because they were pleased with other aspects of their experience.
None of this should suggest that time is not important, and it is in nobody’s interest to return to a world where people are left for hours on end in A&Es up and down the country. But it does make a strong case for using a broader range of measures to assess how well A&Es are performing.
NHS England’s review
Some of the points we have made about what’s most important to patients are being addressed by the proposed new performance targets.
For example, the renewed emphasis on the time to initial assessment and the relative reduction in 12-hour waits at sites piloting the new targets are both positive outcomes so far. But ultimately the focus of the proposed targets is still a measure of time, which doesn’t tell us enough about other factors.
Whether NHS England decides to implement new targets nationally, or stick with the status quo, improving people’s experience is going to come down to how targets are used to drive changes people can see and feel.
Some across the sector have questioned the timing of the review given recent performance to the current target. At Healthwatch we see a genuine opportunity to develop a range of performance measures that work for the system and help patients. But to do this we all need to rethink what the targets are for.
In particular, we need NHS England to set out more clearly how it will use targets, and the data they generate, to shift working practices and cultures to focus on what matters to people. We also need a commitment that any new targets will be kept under review to ensure they are having the right impact.
Crucially, if NHS England does decide to implement a new target or set of targets then it also needs to set out a clear plan for how to maintain transparency around performance reporting, build trust in the new measures and show how they are driving improvement.
Ultimately, the review will only achieve its stated goal of improving patient experience if it leads to the NHS doing things differently, not just counting differently.