Health warning – For the purposes of clarity let me state at the outset that this little reflection is in no way related to any organisation in which I have worked. The views expressed are entirely and sincerely my own.
Let me be blunt.
If you want top class emergency care you have to stop treating it as an exercise in speed dating. For years now we have been looking at the delivery of emergency care and in particular A&E services from the wrong end of the telescope. Worse than that we have seen the public whipped up into such a frenzy that they have done the same.
So let’s go back to basics.
I can tell you that I have always held the view that I want all care to be of a sufficient standard and quality that it should be good enough for someone I love dearly. If it isn’t “good enough for my mam”, then for me it isn’t good enough for anyone. Sadly, the whole system pressure now forces us away from that principle into “hitting the target and missing the point”. Were the powers that be asking me to advise them, I would say “stop counting the hours and start counting the lives” and in particular the quality of the lives lived as a result of outstanding and thorough care.
If I were advising the public, I would say “stop believing the hype.” By and large, you don’t get better care by timing limiting it, though it’s true that you do for some conditions. What gives you better care, is a well staffed department with people who believe they can take the time to think and act correctly on your behalf, rather than worrying as the clock ticks towards 3 hours 55 minutes. In fact I urge you, members of the public, to stand up for your rights. Don’t demand to be seen within four hours. Demand to be seen and looked after to the best possible standard irrespective of how long that takes. That is what will add years to your life as well as life to your years.
The sad fact of the matter is, that all across the country we are seeing inappropriate, sensationalist headlines, critical unsupportive government commentary, ill informed barrack room lawyers and Uncle Tom Cobley and all telling us that we are failing the four hour target. No one is saying and so what? I can tell you now, that personally I absolutely don’t care if I am seen and treated within four hours. If I am genuinely ill enough to need to go to an A&E department, I would expect the expert team to do all in their power to treat me to the best of their abilities irrespective of the time. I don’t want conveyor belt medicine – speed dating with a whole series of people trying to get to know me in three minutes before the bell rings. I want a deep and meaningful relationship based on mutual respect and consideration. My deal is, I won’t come to A and E unless I’m really very poorly and in return I’m happy to wait as long as it takes for you to do the best job for me and I don’t want you to be criticised for that.
What happened to us looking at outcomes not inputs?
You know when you put a cake in the oven, if you only look at how long it takes to cook and not the ingredients it takes to make it, or the preparation time or skill needed, you are not going to get a very tasty cake. True you might get some form of cake at the end but it’s not going to win any prizes at the Women’s Institute show and may not even be fit to put on the table.
I’m not being flippant. This is a serious issue. The more we pressurise staff to push people through the system as quickly as possible, the more likely they are to make mistakes, to suffer burn out and to forget about “caring” and focus on “doing”. I worry about the staff being harassed to death to meet a target that is commonly known as a ‘hanging offence’ and them worrying as much if not more about that, as to whether a patient is safe, comfortable and reassured.
What would you want if it were you?
I can tell you, staff do not come to work to do a bad job. They care deeply about the service they provide and they want to do their very best for patients but we make it as hard as possible for them by focussing on the wrong thing. It really does not matter whether you are seen in two hours or seven hours if you are seen and cared for properly throughout. The care is either good or it isn’t and it is not an arbitrary time target that makes care good.
Let me talk about a couple of exceptions before the pundits start to shout at me. I am fully aware that certain conditions have a golden window of opportunity and that treatment within that time frame enhances the patients’ chances of a good outcome. That is in fact exactly what I am saying. Staff who are not trying to get every single patient through the system against the clock irrespective of clinical need, can focus on those important time critical issues, rather than not being able to see the wood for the trees. We know that people with serious illness who are seen and treated quickly have better outcomes so let’s try to create an environment where clinical staff can make the right decisions made on the basis of what the patient needs rather than the box which must be ticked.
I, frankly, am despondent about the amount of abusive, demoralising public commentary I see about this which never mentions the quality of the outcome for patients but focuses on how long they waited.
Most people who are serious emergencies will have an awful lot done to them whilst going through their A&E journey. They will almost certainly undergo a nurse assessment and a medical assessment so that early decisions can be made on management. They may need blood tests, scans, X Rays. They could require the opinion of other specialists who may be busy saving lives elsewhere in the hospital. They may need a plaster on a fracture, an ECG, intubation, bandaging, cleaning, stitching, pain relief and, oh yes, reassurance. Then there’s talking to family, contacting loved ones, mental assessment, and I could go on. They may indeed spend the first four hours and more with a multitude of people valiantly trying to save their lives and I bet that whilst that is happening not one of those patients thinks “I hope they meet the four hour target”. Actually, I can assure you that for serious emergencies there will not be one member of staff thinking “oh my God we are not going to meet the four hour target with this one” and quite right so they shouldn’t.
But whilst all that is going on, there will be a whole host of people in the emergency department who need to be seen and cared for and who under current rules should be seen and discharged within four hours. Whilst it would be lovely to see that happen in every case if the quality of care is right, it is fundamentally wrong to focus on how fast you can do something rather than how well. It is right to aspire to achieve both but the higher priority should be the quality of outcome not the speed of delivery.
The problem is exacerbated by the fact that emergency departments are also full of people who don’t need to be there muddying the waters. They are almost “speed dating spectators” They could probably go to a chemist or look in a medicine cupboard at home, they could certainly go to their GP or walk in centre. They could ask their mum or look online for help but it’s increasingly a pastime to sit in A&E with something minor often accompanied by friends and extended family, watching the world go by and complaining about the length of the wait, the cost of parking, the absence of entertainment and the limited selection available in the vending machine. If you don’t believe me, watch “24hours in A&E” an excellent insight into the difference between serious emergencies and the sideline commentators looking to occupy their time with a bit of a ‘visit up the hospital’
Let me ask you this.
When you next take your elderly frail mum to hospital after a fall, do you want to see her moved from ward to ward simply to keep patients moving through A&E so the four hour target can be met? Or do you want her to have a thorough assessment, a well structured care plan and perhaps to wait a bit longer with appropriate comfort and support before being taken to the ward she should be in for the remainder of her stay?
I am absolutely not undermining the need for performance standards for the NHS. In fact I could suggest a few which would be better than the ones we currently have – is it not more important for example, to look at how long a patient waited to be first seen and assessed before anything was done at all, rather than looking at the total time in the department when a whole series of appropriate and time consuming things may indeed already have been done ? It’s an important part of understanding what is really going on and in improving. I can also remember where time standards came from in the bad old days where we saw patients waiting on trolleys lying in hospital corridors for very long periods of time. My point is that it should be the right targets for the right reason.
Let me elaborate.
There is no easy fix to the pressure on A&E services. It’s a system problem across the whole of NHS and social care services. Ultimately however, A&E is the default to which people gravitate for many reasons, sometimes when other systems fail, sometimes through choice, sometimes through a lack of knowledge and awareness or a belief that other avenues are not available. Until the whole system is fixed there is little point in placing further undue pressure on already overstretched hospital staff to deliver faster A&E care.
What is the outcome of the four hour target failure?
Does the hospital get more resources to treat more people quicker? You can probably guess the answer- no it doesn’t. In addition to year on year additional financial efficiency requirements it faces, it is much more likely to be fined for not meeting the time standard, irrespective of how well patients were treated in whatever time it took to treat them. When regulators and inspectors look at the A&E department targets, they are focussed on how long it took and how accurately it was counted not what the outcome was for the patient. The system drives everything towards the pseudo “efficiency” target so that the government can say it is assured that A&E waiting times are down – therefore big tick in the box and potential vote winner. My concern is that this is done increasingly at the risk of forgetting about what should really be happening to a patient to get the best outcome for them.
I’ve never been speed dating. I suspect it’s not a very satisfying getting to know you experience. It might be great for first impressions and snap judgements but if you want me to trust you to look after me carefully and treat me tenderly I will certainly expect you to give me more than small talk against the clock.