National targets, process transformation and local consequences in an NHS emergency department (ED): a qualitative study

Abstract

BackgroundIn the attempt to reduce waiting times in emergency departments, various national health services have used benchmarking and the optimisation of patient flows. The aim of this study was to examine staff attitudes and experience of providing emergency care following the introduction of a 4 hour wait target, focusing on clinical, organisational and spatial issues.MethodsA qualitative research design was used and semi-structured interviews were conducted with 28 clinical, managerial and administrative staff members working in an inner-city emergency department. A thematic analysis method was employed and NVivo 8 qualitative data analysis software was used to code and manage the emerging themes.ResultsThe wait target came to regulate the individual and collective timescales of healthcare work. It has compartmentalised the previous unitary network of emergency department clinicians and their workspace. It has also speeded up clinical performance and patient throughput. It has disturbed professional hierarchies and facilitated the development of new professional roles. A new clinical information system complemented these reconfigurations by supporting advanced patient tracking, better awareness of time, and continuous, real-time management of emergency department staff. The interviewees had concerns that this target-oriented way of working forces them to have a less personal relationship with their patients.ConclusionsThe imposition of a wait-target in response to a perceived “crisis” of patients’ dissatisfaction led to the development of a new and sophisticated way of working in the emergency department, but with deep and unintended consequences. We show that there is a dynamic interrelation of the social and the technical in the complex environment of the ED. While the 4 hour wait target raised the profile of the emergency department in the hospital, the added pressure on clinicians has caused some concerns over the future of their relationships with their patients and colleagues. To improve the sustainability of such sudden changes in policy direction, it is important to address clinicians’ experience and satisfaction.

Print media representations of UK Accident and Emergency treatment targets: Winter 2014–2015

“…The media had previously created a feeling of scandal resulting in policy change in relation to treatment times within EDs in the UK (Vezyridis & Timmons, 2014), and the public are influenced by the way in which health policy is reported in the media (Smith, McLeod, & Wakefield, 2005). As such, the way in which breaches of the policy or workarounds ("gaming") was reported by the UK media in a winter in which the targets were regularly breached (NHS England, 2015) was of interest for several reasons.…”

“…In other countries, such as Australia and New Zealand the rationale was that these targets would reduce morbidity and mortality related to delays in individual being admitted from EDs (Jones & Schimanski, ), rather than a focus on overcrowding. Therefore within the UK part of the likely rationale for introducing such a target was critical media coverage which focused on patients waiting “on trolleys” and in hospital corridors (Vezyridis & Timmons, ) unlike in other countries.…”

“…Alongside this, they may also inspire an idea that “something must be done” to prevent a spread of the undesirable issue (Markovits & Silverstein, ). This has led to wide‐ranging policy change including the following: the introduction of targets, including in EDs (Vezyridis & Timmons, ) and job centres (Grant, a); changing provision of services, such as the change from (youth) detention centres to young offenders institutes for young people convicted of committing crimes (Muncie, ), support for those with learning disabilities (Butler & Drakeford, ), and legislation such as The Children Act 1989, which aimed to regulate parental behaviour (Jack & Stepney, ). It has been argued that the media and politicians benefit from such panics as they distort existing power relations (Bonn, ; Markovits & Silverstein, ).…”

“…Therefore within the UK part of the likely rationale for introducing such a target was critical media coverage which focused on patients waiting "on trolleys" and in hospital corridors (Vezyridis & Timmons, 2014) unlike in other countries.…”

“…Alongside this, our own qualitative research with nurses at an acute hospital in Scotland, UK, highlighted that nurses had less time to spend with patients in the ED, including those who were very sick, because breaches were taken very seriously by hospital managers and the Scottish Government (Hoyle & Grant, 2015). This finding was mirrored by research in England, UK, which additionally highlighted the broad range of other clinical specialties that would be involved in ensuring compliance to the target, and the spatial and information technology constraints impacting adherence to the treatment target (Vezyridis & Timmons, 2014). Overall, it can be said that clinical priorities have been distorted by targets, with no discernible benefit for patients (Jones & Schimanski, 2010), but are likely to be detrimental to patient care (Hoyle & Grant, 2015, Hughes et al, 2016Sullivan et al, 2016;Vezyridis & Timmons, 2014).…”