Four hour target prioritises the comparatively wellBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1615 (Published 08 April 2019) Cite this as: BMJ 2019;365:l1615
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Simon Ashworth argues that the 4hr target prioritises the comparatively well. But the evidence he presents mostly doesn't show that and other evidence we have suggests it is clearly not true. He also blames the target for other problems that have nothing to do with the target and everything to do with poor capacity planning in other parts of the hospital. He also argues that the only objective basis for the target is patient "convenience" which is nonsense.
He might be right, though, that the NHS confuses utilisation of capacity as "efficiency" when the clinical need is to treat patients quickly whatever the level of demand.
His argument that A&E patients are prioritised for access to beds rather than those being de-escalated from intensive care is problematic for two separate reasons. One is that a capacity problem in the ICU or in the hospital beds is not in any way caused by A&E: it is caused because of poor capacity planning in those other areas. Blaming the level of patient demand for ruining your capacity plans is not credible clinically or in terms of service quality. The other problem is that his allocation of blame assumes that larger numbers of patients are being admitted quickly to skirt to 4hr target. But this flies in the face of the detailed evidence from A&E which shows that the majority of long delays are caused by those patients who need to be admitted and the reason we can't admit them is because we don't have enough capacity to do so. Few of those patients are in the groups where a longer observation would lead to not admitting them (and, in many hospitals, those patients are streamed to ambulatory care units which should not compete for the main hospital beds).
The same arguments apply to the idea that the target prioritises the comparatively well. Not so. Those with minor conditions can usually be treated and discharges in far less than 4hr: there is no good clinical reason not to treat most of them in less than 2hr (which has been routinely achieved for the majority of non-admitted patients in many hospitals). As for those who need to be admitted, the clinical reasons for waiting >4hr are rare: the need for a bed is often obvious at the point of arrival and the key delays are not in treatment but in waiting for the rest of the hospital to find capacity to handle the admission. Those delays have no reasonable clinical justification. The target doesn't force A&Es to rush treatment decisions: it forces hospitals to reduce administrative delays to accessing capacity. He asks the question the wrong way round. It isn't whether there are clear clinical reasons for treating patients in <4hr (there are, as international studies on A&E delays and mortality have shown and ongoing work on UK data is likely to show when it is complete): the question he should ask is what clinical justification is there for delaying admissions when A&E diagnosis and treatment is complete?
The implication of the strong evidence in the data that it is the admitted patients who suffer the longest delays clearly refutes his idea that the target prioritises the relatively well: the people who need to be admitted are not the relatively well and the reasons they are delayed are only rarely because the A&E department needs to give them more treatment.
As has been said many times in previous discussion the key reason why the 4hr target can't be met is not because A&Es do not have the capacity to treat them quickly: it is because the hospital does not have the capacity to admit them quickly. This is a problem exacerbated greatly by the assumption that the target is purely an A&E problem. It isn't an A&E target, it is a hospital target but too many hospitals have ignored the implications for their inpatient capacity planning which need to be able to cope with the (fairly predictable) surges of demand from A&E.
His arguments for some condition-specific targets are reasonable: every hospital should have them. But not as an alternative to 4hr. If the 4hr target is relaxed, it does not create more capacity anywhere to treat those time sensitive conditions faster (not least because the bottleneck isn't usually inside A&E). And the implication of a more relaxed target which focuses on a narrow range of time-sensitive conditions is that the general speed of treatment in A&E will get slower. This will create more crowded A&E departments which will make it harder–not easier–to treat the patients who should be prioritised.
Competing interests: No competing interests