I started working in the NHS in 2012, and would regularly rush around busy A&Es as the most junior of doctors like an angry wasp, buzzing between what felt like tens of patients, struggling to manage all the plates in the air.
At the time, a recent A&E had closed and there were no plans to open another. We would get regular calls about patients “breaching”, the term we use for a patient waiting longer than four hours to be seen, treated, admitted and discharged. The coalition government had just reduced the four-hour target from 98% to 95% in 2010, and, at the time, it felt like we would get more urgent calls about “breaching” patients than very sick ones. Hospitals still get fined from their budgets if they miss these targets, which always seemed a ridiculous way to address a struggling service, so we would feel the pressure not just from the patients but senior doctors and management as well.
Flash forward to 2020, and I look back on those days with rose-tinted glasses. Since 2015, the A&E target hasn’t been met in England at all, and fell from one in eight patients waiting over four hours, to one in four this winter. A&E sits at the crux point between the community and the hospital, and when you walk in to a heaving hospital you can physically feel the strain: patients queueing in corridors, the emergency alarms, the strained voices of the receptionists. The worst part is the hungry eyes of the patients waiting to be seen and their families; even when I’m not working I find it difficult to walk past.
As a busy heart doctor I have taken lots of calls from A&Es about “breaching” patients, and sometimes that does mean prioritising the sickest patients can become confused by the target. But that reflects the ever increasing volume in our hospitals, up 4% year on year for the past 10 years, and the lack of resources to follow it, average funding increasing by only 1.5%.
Matt Hancock has said that this target being scrapped would be “clinically appropriate”. If that were the case why has it been in place for the last 10 years? Or why wasn’t scrapping it part of the Tory manifesto? I feel it is more than coincidence that this is the second target to be binned by this government in a year: the 18-week target for urgent operations went last year as well. As a doctor under constant scrutiny in an intense and difficult environment, this government’s constant and repeated ability to escape accountability infuriates me. The 18-week target hadn’t been met for years, the two-week target for cancer diagnosis hasn’t been met for years, and now the A&E target is flat-lining, instead of an urgent solution, it’s the target that becomes the problem.
Despite our own personal nit-picking with the four-hour target, on a system-wide level it is a really good barometer of what the NHS is really like on the ground: ever busier clinics, ever harder to get to GPs, ever sicker and ever more patients. To take my daughter to the GP last year was a four-week wait. There isn’t a target for that, and this is probably exactly why.
I don’t believe the four-hour target is being scrapped because of “clinical need”, and neither do the Royal College of Emergency Medicine, who have said there isn’t “a viable alternative”. Without the four-hour target we could very well let low acuity patients wait in A&E for literally days, but there wouldn’t be any data to let the outside world know how bad it’s gotten. It’s another move to reduce the headlines that are damaging to this Tory government, but devastating for the actual patient’s here on the ground. A cynical move to escape scrutiny and mendacious to suggest otherwise.
I’d imagine this will be the start of removing more and more of these targets and metrics. Soon, the only way to evidence the crisis enveloping our healthcare system will be via the photos we are forced to take on our phones. That is, unless the prime minister pockets them too.
Dominic Pimenta is a cardiology registrar and author. He tweets at @juniordrblog.