8. Stop-watch care
Matter for discussion submitted by the RCN Lothian Branch
That this meeting of RCN Congress discusses the impact of the four hour emergency care target on patient care and staff morale
Report on this discussion
Lisa Falconer, of Lothian branch, introduced a matter for discussion on the pros and cons of the Department of Health’s target stipulating that no patient should have to wait more than four hours for admission to a bed, transfer elsewhere or discharge.
She said all four UK countries were now behind this target. But she wondered whether this was prompting clinical decisions that were not in the best interests of the patient. ‘Has the clock become more important than the clinical process?’ she said.
She asked Congress to consider the effect of the target on the working life of nurses; whether it was sustainable; and whether it drove up the quality of care or not.
The debate was very wide ranging, and there was a plea, not agreed to by delegates, to extend it by a further ten minutes.
Soline Jenam remarked that older patients’ needs sometimes get lost within the targets system, and urged delegates not to play the Government’s targets game any more. David Mathers said there was a rush to get patients into a bed – any bed – sometimes inappropriately.
But Denise Chaffer reminded delegates to ‘be careful what we wish for’. A few years ago there was enormous concern about very long waiting times in A&E, a point reinforced by Zeba Arif on behalf of the UK Stewards’ committee, who said targets were a mixed blessing.
Emergency Care Association members Heather James and Richard Brownhill spoke of the pressure of targets on emergency nurses. But Linda Bailey asked Congress ‘not to reject sensible targets because people are implementing them in non-sensible ways’.
Background
In the late 1990s and the early 2000s many emergency departments in the UK were struggling with high demand and poor patient flow. During this period it was not unusual for emergency care patients to be kept on trolleys awaiting hospital admission for over 12 hours, and sometimes up to 72 hours. High profile negative press coverage and public opinion meant this issue became a priority for the Labour government.
In 2000, the Department of Health set a range of emergency care access targets in its NHS plan, and in 2001 the government published Reforming emergency care (Department of Health, 2001) which established waiting time targets for all UK emergency care patient contacts; by 2004 no one was to wait more than four hours in an A&E department (from arrival to admission to a bed, transfer elsewhere or discharge) and that average wait times should fall to 75 minutes.
The new standard was introduced into the NHS in England in 2002; it is expected that 98 per cent of patients presenting to emergency departments will be seen, treated, admitted or discharged within four hours of arrival. In 2005 the target was introduced in Scotland and by September 2007, 97 per cent of patients’ attendances were meeting the four hour target. In Wales, the NHS Service and Financial Framework for 2007-08 includes a target that states that 95 per cent of new patients (including paediatrics) should spend less than four hours in a major emergency department until admission, transfer or discharge, and that no patient will wait longer than eight hours. In Northern Ireland the current 12-hour standard will change to four hours in March 2008.
The RCN’s Emergency Care Association (ECA) supports the broad principle of the four-hour target and believes its introduction has improved performance, patient flow and patient experience in many emergency departments. However, it acknowledges that pressure on staff to meet the target is enormous and that at times it feels like the target is more important than quality. Research amongst emergency nurses supports this view, but questions the sustainability of a 98 per cent target (Mortimore and Cooper, 2007).
Many emergency care doctors remain resolutely opposed to the target. A recent BMA survey (British Medical Association, 2007) showed that 54 per cent of respondents believed the four hour target is being met by their department, despite official figures submitted by the trust. A third of respondents claimed that data manipulation was used in order to meet access targets and a half (53 per cent) said additional agency or locum staff on short term contracts were being brought in to help. Almost all (95 per cent) of respondents said they had experienced direct or indirect pressure to meet the four hour target (BMA, 2007).
In 2004 the National Audit Office (NAO) found evidence that reducing the time patients spend in A&E has led to increased patient satisfaction. While speeding up access is a positive consequence of the targets, there could however be an unintentional impact on quality. The NAO also noted that the measurement of the quality of clinical care and national benchmarking has been much more limited.
References and further reading
British Medical Association (2007) Emergency medicine: report of the national survey of emergency medicine, London: BMA. Available from: www.bma.org.uk
Department of Health (2001) Reforming emergency care: first steps to a new approach, London: DH. Available from: www.dh.gov.uk/en/Publicationsandstatistics
Mortimore A and Cooper S (2007) The ‘4-hour target’: emergency nurses’ views, Emergency Medicine Journal, 24 (6), pp.402-404.