I was driving home last night when I heard on the Radio 4 evening news that one of the top stories was a failure of emergency departments in England over the last week to meet the fabled “four hour target”.
The four hour target, which was introduced by the Department of Health in 2003, states that 95% of people attending emergency departments in the UK should be seen within four hours.
Or that’s what I hear every time there’s a news item relating to this target, so let’s clear up a couple of things.
And the first thing is that the four hour target states that 95% of people attending emergency departments should be triaged and seen and treated and moved out of the department within four hours.
I’m not quibbling the rights or wrongs of the target; we could go round and round on that forever. It’s an arbitrary number. It’s been the same arbitrary number for eleven years. That allows us to measure and compare and I suppose gives part of the impetus to improve performance. It has as much value as any other number that might have been chosen, which is to say that it has enormous statistical value and absolutely no moral value.
The target is what it is, but if we’re going to let the media take the NHS to the cleaners every December for a target that it’s failing to meet then I think they should be obliged to talk about that target as it is.
Even with those parameters, the four hour target was achieved for 91.8% of people attending emergency departments in England in the first week of December.
And that figure says something, but it doesn’t say that 8.2% of people attending English emergency departments last week were still in the waiting room at the four hour mark.
We don’t have any December figures for emergency departments in Scotland yet, but the media presume that they will be comparable with England. Last weekend, I was the receiving medic for an inner city Scottish hospital. I spent the first weekend of December trapped in ED (and I do mean trapped — I ate only because my FY1 delivered lunch and caffeine to me, which probably qualifies as abuse of one’s juniors on my part). I cut through the waiting room a lot. That less than 10% of patients were in the department for longer than four hours is fairly remarkable to me.
So far as I can tell, the patients who are well enough to be discharged home straight from ED are not the ones for whom the target falls down (although it isn’t difficult for me to envision a situation in which that process as a whole could take longer than four hours). The target falls down for the patients who are seen and, having had their treatment started, need to be admitted to the hospital.
There is a bed crisis in hospitals in the UK. I don’t know if you’ve noticed. It hasn’t been caused by doctors or nurses or AHPs, who consistently work their socks off and then some. From what I’ve witnessed, it is for the most part being caused by inappropriate attendance at ED less than politicians would like us to believe. It is being exacerbated by those same politicians, who bafflingly seem to think that closing hospitals and reducing the number of available beds is the way to fix it.
(Spoiler: It’s not.)
If a person needs to come into one of those beds, they will be found one.
If the specialty to which they need to come does not have a bed available right now, two things will happen.
First, we will come to you.
You’re having an asthma attack? We’re not going to withhold oxygen and nebulisers until you get to the respiratory ward. You have a raging infection? The cupboards in ED have antibiotics too.
Second, we will keep you in a place of safety.
And it breaches the four hours and governments don’t like it and patients don’t like it and the media sort of love it, but emergency departments are a place of safety. And are better for patient safety than transferring unstable patients to a non-ED bed across a city, or giving a less sick patient a higher priority for a bed than a sicker one merely because of waiting time, or discharging patients inappropriately. And the days when those things are true are more frequent than anyone who works for the NHS would like them to be, so when they are true we do the very best we can with what we’ve got and we go home at the end of the day knowing that we worked for the good of our patients and not for obedience to a government target.