Performing or not performing: what's in a target?

Abstract

This paper analyses how providers have coped with the 4-hour target over the past 7 years. To do this, we used publicly available data from NHS Digital to track how long patients remain in accident and emergency (A&E) departments and their 'attendance disposal method'. Using this tool, we compared two A&E departments with similar arrival patterns and age profiles and that perform equally well against the target in a specific year. However, these hospitals exhibit very different underlying behaviour. Over 7 years, both exhibit a general increase in length of stay, increasing number of patients being admitted in the 20 minutes preceding the 4-hour target, and rising numbers of patients that breach the target. Despite the two hospitals having similar input profiles there is a 12 percentage point difference in the number of patients who leave the A&E department in the last 20 minutes. This operational information is not visible simply by monitoring the single existing metric. We conclude that the 4-hour target in isolation is an inadequate measure and we reflect on the difference between selecting measures for policy-level review, and for operational management. A link to download the graphs for each A&E in England is available.

Keywords: 4-hour target; A&E; analysis; hospital.

Fig 1.

Age (A) and arrival time (B) profiles of patients at Hospital A and Hospital B reported for year 2014–15. Data from NHS Digital.

Fig 2.

Profile of the time that patients spent in the accident and emergency (A&E) departments of Hospital A and Hospital B reported for year 2014–15. Data from NHS Digital.

Fig 3.

Performance against the 4-hour target from 2008–09 to 2014–15 for the accident and emergency (A&E) departments of Hospital A and Hospital B. Data from NHS Digital.

Fig 4.

Percentage of patients who left the accident and emergency department in the first 2 hours following arrival, between 3 hours 40 minutes and 4 hours, and patients who had a length of stay exceeding 4 hours for Hospital A (A) and Hospital B (B). Data from NHS Digital.

Fig 5.

Percentage of patients who left the accident and emergency department in the first 2 hours following arrival, between 3 hours 40 minutes and 4 hours, and patients who had a length of stay exceeding 4 hours by discharge destination for Hospital A (A) and Hospital B (B). 1 = discharged in 2 hours; 2 = discharged between 3 hours 40 minutes and 4 hours (ie in the last 20 minutes of the target window); 3 = discharged after 4 hours. Data from NHS Digital.

Fig 6.

Length of stay in accident and emergency (A&E) department for ­admitted and discharged patients in England in 2013–14. Data from NHS Digital.