Politicians beware: The NHS will never again meet the four-hour A&E target

To meet the target would require a combination of the following: the addition of well over 20,000 beds – and the clinicians needed to staff them – to smooth patient flow out of emergency departments on to wards; a significant increase in social care capacity to speed discharge; a massively increased contribution to meeting urgent care needs by primary care; and a revolution in the use of data to identify and intervene with patients before they experience an acute episode.

All of these things – and a range of other measures that would improve urgent and emergency care – could, should and hopefully will happen in time. But the idea that enough of them will take place over, say, the next two parliamentary terms, is for the birds.

No government will be able to afford the levels of investment needed, and if some economic miracle took place to make it possible, the necessary staff could not be trained in time. Technology-driven interventions will eventually have a big impact, but as the Wachter review so memorably concluded, any kind of meaningful contribution from new technology is likely to take at least 10 years.

NHS leaders, including many trust chief executives, have accepted the impossibility of getting back to 95 per cent for some time. That view now appears to be widely endorsed at national, regional and local level.

This firmly held and widespread belief is thrown into contrast by the equally confident assertion that constitutional standards for elective care can be restored in five years.

The five reasons it matters

Does it matter that the 95 per cent four-hour target will never be achieved again? After all, the “interim” target for 2024-25 is just 78 per cent.

HSJ argues that it does for five reasons.

The first is that the NHS is being held to false measure. Pretending the 95 per cent is achievable, throws considerable shade on even very significant advances in performance. A trust achieving, say, 85 per cent is doing incredibly well in the current context but it is “failing” according to the constitutional standards.

The second reason is the impossibility of achieving the target, shoves the whole measure into disrepute. What is the point of trying to hit a target that is forever out of range?

The third reason is that it is – now – the wrong target. Much has been written about why a measure set two decades ago is past its sell-by date. However, one objection to its continued existence looms above all others, namely that a blanket four-hour target inevitably means A&E departments are incentivised to treat the least sick patients as they are much more likely to be discharged within four hours.

To put it another way, the level of demand and lack of capacity at all stages of the UEC pathway mean the existing four-hour target is undermining the care of the tens of thousands of people who arrive at A&E having suffered a stroke, heart attack or equivalent serious episode.

The fourth reason, is – as we have seen on electives – the service is in full-on planning mode to meet the expectations of a new government. The service needs to know what it should be aiming for.

The fifth, and last, reason, is that Labour has committed to achieving the four-hour waiting time target. You can expect the Conservatives to match that pledge. Both parties should be very careful in making such a commitment when it comes to the four-hour target.

An eye-watering amount of money

Should they wish to pursue such a pledge they must be prepared to spend an eye-watering amount of money, and to effectively crowd out any planned improvements in, say, primary care or mental health. In purely political terms, they will also be signing themselves up for likely failure.

What then, is to be done?

The obvious answer is to develop a new performance measure, and the obvious counter to that solution is, “er…haven’t we already done that?”

The national clinical review of standards which proposed replacing the four-hour target with a range of new measures was the right idea, poorly executed. The suggested solution lacked a “retail” offer that could be easily understood by politicians, press, and the public – and be supported by the Royal College of Emergency Medicine, for whom the four-hour target is the most valuable of totems.

However, that is in the past. Politicians, and sceptics in the service, must encourage NHS England, the RCEM and other interested parties to lead a debate about what kind of UEC targets would deliver the best mix of timely, effective and safe care.

The first order of business should be to determine a target for the most serious or “type one” patients. Next, the debate should look at greater alignment between the time people with minor illnesses and injuries should wait regardless of whether they are seeking treatment in primary or secondary care. The present four-hour target is proactively inviting patients to bypass primary care in order to achieve the speediest treatment.

That debate must start now and conclude in time for the parties to include realistic commitments to improving urgent and emergency care in their election manifestos.