Each weekend I look back on the working week and post some reflections. The theme this week is the continued winter pressures




I’ve had a couple of days off this week, which I spent preparing some conference talks I’m doing in January, and in repeated telephone conversations about the continuing urgent care pressures on our three hospitals.


The calls with the Trust were to keep in touch and offer support to our exhausted clinical teams who have now been managing unprecedented demand for several weeks without let up. The other calls were to ‘remind’ me about the need to achieve the 4hr target, which set me thinking (again) about our regulatory system.

All parts of our local health system have struggled with capacity this winter. Yet the regulatory framework is focused on hospitals – it labels us as having ‘failed’ because we didn’t meet the 4hr target in the third quarter. Specifically, we ‘failed’ because 93 or 94 people out of every 100 who attended ED were seen, treated, and admitted or discharged within 4 hours, rather than 95, no matter how pressured the system was, or what the clinical outcomes were.

Our processes are far from perfect, I know that. However an equally valid explanation would be that the pressure occurred due to a failure (of commissioning) to manage demand and provide accessible alternatives to hospitals, or to support timely discharge. But that isn’t discussed because it isn’t measured?

This matters, because if it isn’t discussed, then it won’t be remedied. Worse, it may put pressure on ‘failing’ hospitals to adopt sub-optimal practices?


My doctors run a ‘front loaded’ system, meaning that patients are fully worked up, given initial treatment, and stabilised in ED when clinically appropriate. This is important, particularly out of hours, as ED may be the safest place to be when close observation is needed. A process of ‘triage and pass through’ to a bedded area will stop the clock quickly, but could place the unstable patient in an area where support is less immediate.

I would choose this system for myself or my family, because it is safer. Our good mortality rates provide assurance about this process. But it is harder to hit the 4hr target, particularly when attendances are high, because it only measures the time in ED.

A critical look at 4hr performance across the country would be illuminating. I find it difficult to believe that those Trusts who continually struggle with the 4hr target are all slow to learn, or poor at implementing change. My guess is analysis would show high attendances with a high proportion of ‘majors’ and ambulance ‘blue lights’, and/or a local population with high levels of need, or less accessible or effective general practice or community services.

Currently, huge effort goes into constantly refining efforts to achieve 4hrs, when in fact the focus needs to be on other components of the health system. Maybe, the new clinically-focused commissioners will see this and act differently?.


We should make 2013 a year for change. The 4hr target is a good target, but badly applied. We should stop thinking ‘pass or fail’ for hospitals, and instead think, analyse and understand what the measure is telling us. Then will we connect with staff, see the solutions, and make the right changes.

The Francis report is imminent, and most expect it to be critical of the systems of commissioning and regulation that were in place at the time. We have new commissioners coming in April, is it time for a new approach to regulation too?

In his article ‘The NHS in England in 2013’ in this weeks BMJ, Chris Ham comments on this. I’ll give the last word to him:


“In formulating his recommendations, Robert Francis must avoid the temptation to see regulation as the main solution to the problems that arose at the hospital. He should focus instead on the role of leadership and culture in creating environments in which clinical teams can provide the best possible care within available resources