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From A&E waiting times to the Windrush scandal, beware bureaucratic targets

Posted by on January 22, 2020 in Blog, Health | Comments Off on From A&E waiting times to the Windrush scandal, beware bureaucratic targets

From A&E waiting times to the Windrush scandal, beware bureaucratic targets

Last week, health secretary Matt Hancock signalled an important change of strategy.

Accident and Emergency Departments have a target that 95 per cent of patients should be admitted, transferred or discharged within four hours. Hancock suggested that the target will be scrapped. Instead, wait times will be determined by clinical need.

Cue predictable hyperbolic outrage. The president of the Royal College of Emergency Medicine, for example, claimed that this change would have a “near-catastrophic impact on patient safety”.

The NHS is not meeting the target by a long chalk. In December, the actual figure assessed within four hours slipped to under 70 per cent.

A key reason seems to be increased demand for A&E services. Since the Conservatives came to power in 2010, admissions have increased by almost 25 per cent.

It is inherently implausible to imagine that cases of genuine emergencies have risen by this amount. Road casualties, for example, far from increasing, have actually fallen by 24 per cent since 2010.

There is much anecdotal evidence to suggest that people are bypassing GP surgeries and turning up at A&E with trivial complaints. Perhaps GPs are so oversubscribed that people who cannot get appointments go to hospital instead, or maybe limited out-of-hours care means that patients feel they have little choice if they fall ill at weekends.

But regardless, the lengthening waits indicate excess demand for A&E care.  Some form of rationing is necessary to allocate resources and to decide who gets treated.

There are two ways to ration. One is by price — whoever is willing to pay the most gets dealt with first. The other is by queue.

Even the most hardline free marketeer would surely balk at the idea of making people involved in genuine accidents wave their credit cards. So queue it has to be. And in such circumstances, it is entirely appropriate that decisions on who to treat first should be made on clinical grounds rather than a purely arbitrary target on the length of wait.

This controversy demonstrates the wider problem with setting targets: sooner or later (and usually sooner), people work out how to game them.

In A&E departments, once a patient has waited more than four hours, they have zero priority. The hospital incurs no more downsides if the wait is 14 hours rather than four hours plus a single minute.

We see this in other sectors too. Schools can, for example, meet exam targets by getting rid of weaker students — hardly what the target was designed to achieve.

And the Windrush scandal had its origins in the Home Office targets for the numbers to be deported. Officials could have tried to track down members of eastern European criminal gangs. Instead, they focused on the seemingly easier task of deporting elderly people who had lived in Britain for decades. They worked out how to meet the targets by minimising their effort.

Examples of gaming the system proliferate. Hancock is to be applauded for taking the first step to dismantle the culture of bureaucratic, counter-productive targets.

As published in City AM Wednesday 22th January 2020
Image: Ambulances outside A&E Department by D-G-Seamon via Wikimedia licensed for use CC BY-SA 2.0