Dear Mr Lansley,
Yesterday at 4pm I had cause to attend the A&E department
at a local hospital. Due to the nature of the symptoms I was experiencing, the
medical staff needed to undertake a complex and comprehensive initial
investigation. As this was almost at a conclusion (shortly before 8pm) I was
informed that in order to meet Government targets I would need to be moved out
of A&E and be admitted to a ward. I was also told that it was likely that I
would be discharged within an hour, subject to the results of the tests.
At this time the department was
relatively quiet - there appeared to be sufficient staff on duty in A&E,
cubicles were available and the waiting room was practically empty. In other
words, there was no medical reason for me to have to move location at that
time; neither did another patient require my cubicle. A short time after being
admitted to the ward, the Doctor in charge of my case visited me and confirmed
that I could be discharged.
I appreciate that Government NHS
targets were probably introduced with the good intention of improving clinical
care for patients, but I am troubled by the actual effects that they cause at
ground level. In this case, I was left in no doubt that my medical well being
was at the forefront of A&E staff members’ concerns, yet they were
obviously hampered by these arbitrary numerical targets, which do little for
clinical care and actually impede the efforts of front line professionals.
The effect of moving me out of a
department that had sufficient capacity to treat me placed unnecessary strain
on a ward that ultimately did not need to become involved in my treatment. Had
the four-hour admittance time target not been in place, then my treatment would
have run its course within A&E with minimum impact on that department’s
operational capacity, and no impact on the ward at all. As it happened, the
target generated additional administrative activity for staff from both
departments that was ultimately unnecessary. It also caused the Doctor in
charge of my treatment to become abstracted from his core function in order to
brief ward staff and visit me in another part of the hospital to explain
aspects of forthcoming outpatients treatment and inform me I was being
discharged. This could have been quite easily achieved in my original location,
and I am left in no doubt whatsoever that the remainder of my treatment would
have been carried out in A&E had that department not been under pressure to
meet the time-based target.
Had the target not been in place
I am also certain that the ultimate outcome of my hospital visit would have
been the same, as well as being a quicker and smoother experience. I am also
convinced that unnecessary handover procedures, delays and administrative
functions would have been avoided, thereby releasing capacity to attend to
other patients. Other than exceeding the target time, there would have been no
adverse impact had I been permitted to remain in the A&E department pending
the results of the tests. I have no doubt that the A&E staff felt compelled
to comply with the admission time target by ensuring that I was ‘off their
books’ within the specified time period. This is despite the obvious ability
and professionalism of those who attended to me. The problem here is not a
‘people problem’ – it is a system problem caused by inappropriate external
pressures and perverse incentives.
Taking into account my
experience, I would be grateful if you could demystify exactly how my NHS
experience has been enhanced by the existence of Government targets, and
explain how this particular target has contributed to improving clinical care
at this hospital? I am also keen to understand why, in the event that I had
‘overstayed’ in A&E, it is appropriate that the hospital should
subsequently be penalised for failing to meet that target?
I ask that you consider your
answers carefully as I am not prepared to accept that this is an isolated case
of bad individuals behaving inappropriately – it is an inevitable consequence
of the inappropriate pressure associated with target-driven performance
management.
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