You can’t “Click & Collect” Healthcare #WILTW

This is the 143rd #WILTW

Leaked reports showed England’s Accident and Emergency Performance in January to be the worst on record. This was probably the least inflammatory leak in healthcare history; anyone working or experiencing the system will have appreciated this.

Before I go further it is vital to point out measuring quality by the 4 hour target is about as sensible as measuring Donald Trump’s presidential aptitude by the number of retweets he gets. The percentage of patients discharged or admitted within 4 hours tells you nothing about the patient’s outcome or experience. You can be seen and sent home in 15 minutes and have had a dreadful time at the hand’s of rude staff who have misdiagnosed your condition. Conversely you may spend 6 hours in the Emergency Department receiving compassionate care with everyone working hard to aid you safely going home and have had a very positive experience.

I am in a small minority of clinicians who think the introduction of the 4 hour target was a good thing. It transformed Emergency Care from an under-appreciated specialty to a more patient centred and respected one.

Sadly it is no longer relevant to the needs of our health economy. While it might be a barometer of a whole healthcare system the inability to come anywhere close to the standard has devalued its use as a performance metric. It has also, unintentionally, played into the public ‘on demand’ cultural psyche. As a result of the 21st century’s explosion of communication technology virtually any service is now instantly available, or bookable, at the users preference. Sitting with your phone in front of the television you can organise your next months food, entertainment, clothing, cleaning and financial activity. What you can’t do is pick when you need the toilet or be ill.

I hate it when there are lengthy waits to be seen. The waiting room look is a challenging, and a potential cognitive, distraction. The majority of parents are concerned about their child and just want someone to reassure them they do not have anything serious. Waiting hours for this to happen while their infant is restless and miserable is not pleasant for them.

But sadly there is an increasing trend of people coming to the reception or nursing desk asking how long the wait is. “I have been here an hour -why haven’t I been seen yet?“. In the last decade I have seen a 2 hour wait become as unacceptable to some as a 4 hour one used to be. Emergency care can’t provide a click and collect format. There are a finite number of staff dealing with an unpredictable work load. As volumes of patients increase it becomes more and more difficult to deliver a timely service that meets the expectations of a generation used to getting what they want, when they want it. An argument could be made that 82% of patients having a disposition within 4 hours, given the constant increase in presentations, is actually something to be celebrated not bemoaned.

This doesn’t make long waits acceptable, and doesn’t mean the system shouldn’t work very hard to provide a equitable, safe and effective service. However I think like @ERGoddessMD that the rise of waiting time billboards is going to compound this problem not make it better. We try hard to make the complex simple but there are some challenging public debates that need to be had. While your smartphone may continue to provide you instant access to the world, it is unlikely that emergency and urgent will do the same.

What did you learn this week? #WILTW

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  1. The 4 hour target was undoubtedly a good thing but it has been a victim of its own success and a double edged sword for the RCEM. The target placed a huge emphasis on that aspect of acute care and led to a great increase in funding and staffing. Unfortunately, the blunt nature of the approach meant that ED could become more attractive than primary care and GP investment has suffered over the same period. I’m not sure that the 4 hour wait is a genuine barometer of the health service in general, although it might well be the one that’s easier to publicise.

    One of the challenges of the fragmented system we work in is that we are all encouraged to fight for our own piece of the pie and we ultimately end up competing with other services rather than working together. Commissioning Groups are obviously supposed to address this but when the pie is no longer big enough to feed the mouths at the table, efforts to shrink once portion to help another just won’t work.

    I’ve not seen you mention the crisis in General Practise in Northern Ireland where they are threatening to resign en masse. That is likely a greater harbinger of things to come but seems to get little coverage in the UK