Question: NHS - the case continues

The measurement and target culture A report analysing the failures of the mid-Staffordshire NHS Foundation Trust placed some of the blame on the performance measurement system. One performance metric that was criticised was the Accident and Emergency (A&E) four-hour, waitingtime target. Staff told the Healthcare Commission that there was a lot of pressure on them to meet this target. Several doctors recounted occasions where managers had asked them to leave seriously ill patients to treat minor ailments so the target could be met. One had even been asked to leave a heartattack patient being given life-saving treatment. Nurses reported leaving meetings in tears after being told their jobs were at risk after breaching the target. And the report concluded that patients were sometimes ‘dumped' into wards near A&E with little nursing care so the targets could be met.

The four-hour target, which in simple terms aims to ensure that patients are treated and either admitted or sent home within four hours, at first glance seems straightforward. However, on further consideration it is much more complicated to enforce. Not all patients that come in have the same requirements; indeed doctors had identified that some groups of patients such as those with chest pains, recovering from alcohol or drug overdoses, and those too elderly or vulnerable to be discharged in the middle of the night should be exempt. Some hospitals were getting round the fourhour target with observation wards attached to the A&E which patients could be admitted to. Others refused to accept patients into their A&E departments from the ambulance so that the ‘four-hour clock' would not start ticking. Unthinkingly, trying to meet this simple but ultimately misconceived target seriously damaged patient care.

Case questions:

· Do you think it is appropriate to allocate performance measures of any sort in organisations that deal directly with people with potentially life threatening conditions?

· Investigate other performance measures used in the NHS. Try to find some that are misconceived and therefore open to abuse.