Thread by @chrisbiggin

1. Potentially controversial and unpopular (and long)view alert!

Take as a given that I think the 4 hour target has on balance been good for patients and A&E. It was necessary in 2004 to create some leverage on whole acute systems.

2. They complacently would allow long backlogs to occur in A&Es which were both unsafe and a poor patient experience.
It did that pretty well for almost 10 years while resource to achieve it was somewhere close to what its delivery needed.

3. The changes in ED pressures in recent years are down to:
- patient complexity (frailty and the result of NHS managing complex patients as outpatients)
- exit block (bed closures)
- delivering the bulk of ambulatory care
- guideline compliance
- volume growth

4. The 4HT is still needed to push the system to not make patients needing to be admitted to a bed wait for hours after their ED assessment. This is where there has been unacceptable growth in 4hr breaches, including England’s fiddled 12hr figures. Many/most are elderly & frail.

5. A key success of ED in the past 10 yrs has been assessing and diagnosing patients to increasingly stringent guidelines (cauda equina anyone?) AND DISCHARGING THEM - doing large chunks of work previously done elsewhere in the hospital as an inpatient

6. A tweak to the target that somehow recognises that delivering complex ambulatory care as a one stop shop can and does take more than 4 hours is not necessarily a bad thing and removes perverse incentives.

7There’s another bit
The most significant growth in volumes in the past few years has been in relatively well, non-emergency patients that happily pay their Amazon Prime / Netflix on demand subscriptions and have similar expectations of one of the cheapest western health services

8. Some of these are ‘minors’ but many are simply not willing to wait in the old-style outpatient queue. Some are self-referral; many are directed by other parts of the health system - 111, receptionists, GPS, specialist nurses, clinics, contact systems

9. Many are due to (correct) earlier-than-previously discharges with ED ending up (without any planning for this) acting as the ‘come back if you’ve got a problem’ port of entry for other parts of the system

We do not collectively pay enough tax to have this premier on-demand service for non-emergency (I didn’t say minor) wishes. Ideally these people would be seen elsewhere but the public AND if we’re honest, the rest of the NHS has come to expect/rely on this sort of non-wait access

11. I would have few qualms in not applying a 4 hour target, or any target to this sort of ‘roll up, drive-thru’ workload that would previously have had to wait elsewhere.

12. It will be fiendishly difficult to find ways to design more appropriate targets for each of these groups, capture that info and even more so, to sell any case for change (as witnessed over the past few days)

13. The reason the proposed change is viewed with cynicism as an attempt by the DHSC to get itself off the hook for repeatedly failing is that I suspect it probably is exactly that to a large extent. It doesn’t mean that there’s not something right about it though.

14. Using @EDdocUK Matthew Cooke’s 2010 balanced basket of measures, or integrating 4 hr wait with @RCEM_VP Chris Moulton’s Aggregate Patient Delay metric may end up being the answer. But the blunt tool of 4 hours ALONE, helpful thought it has been, belongs to a past era.

15. And yes - I know there’s primary care streaming, and alternative dispositions, and clock-stop wheezes and CDUs - but it all adds to the gaming, never mind the distortion of tariffs, data comparability and trust mortality ratios. Appropriate targets remove the need for dodges.

16.The reality is that 4 hours is a beautifully simple concept, & the politics and media side will lack nuance and understanding to allow change. And yes, lack of resourcing is still the bottom line. But do those of us that ‘get it’ truly believe a flat 4 hrs is the right thing?