Targets in A&E make people cheat

A couple of days ago I wrote about an analysis of Accident and Emergency department (A&E) waiting times that the NHS Information Centre released. It showed that a disproportionate number of patients were seen to in the 10 minutes before the 4 hours waiting time target. The Nursing Times ran a survey in response to that analysis which found that across the UK, trusts are cheating to be seen to hit the target. To quote from their article,

Forty per cent of nurses believe their colleagues are involved in helping to meet waiting time targets by underhand means, often referred to as “gaming”.

And one in 10 hospital nurses say they have personally been asked to engage in gaming to help meet waiting times this autumn.

The article goes on give a few examples of the type of gaming that happens:

  • Discharge times for patients are changed
  • Patients are temporarily moved from A&E to corridors, observation areas and theatre recovery wards
  • Patients are unnecessarily admitted to mixed-sex bays or specialist wards
  • In one trust, part of A&E was re-badged as a “clinical decision unit” and is now longer deemed part of A&E

This is no surprise. Targets make people cheat. It happens all the time and not just in the NHS. Remember the teachers in Bolton who were suspended over allegations of cheating to help students in GCSE language exams?

Targets do not, and never have driven improvement for patients they only drive inventiveness to try to hit the target by any means necessary. There is small cheating like adjusting discharge times and then institutional cheating by relabelling a part of A&E.

It is all wrong.

It is morally wrong but there is also the issue of the opportunity cost. All this effort and inventiveness is going into fiddling the system. Imagine if all that innovation went into improving the service. What about the boost to morale for the staff when they were released from the target and from the need to cheat? Think of the benefit to patients to feel that their care was the most important thing to the staff.

The other hidden problem is that when the figures get changed you no longer have reliable data upon which to base genuine improvement.

Anyone who thinks targets drive improvement has never been moved to a ward in order for the hospital to meet a target, only to be forgotten about because they should never have been transferred there in the first place.

Best,

Rob

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