NHS targets are performance measures used by NHS England, NHS Scotland, NHS Wales, and the Health and Social Care service in Northern Ireland. These vary by country but assess the performance of each health service against measures such as 4 hour waiting times in Accident and Emergency departments, weeks to receive an appointment and/or treatment, and performance in specific departments such as oncology.
History The Major Conservative government first set public targets for the NHS in the 1990s – for example, guaranteeing a maximum two-year wait for non-emergency surgery and reducing rates of death from specific diseases.
The subsequent Labour government introduced far more targets and managed performance far more aggressively - a management regime sometimes referred to as 'targets and terror'. Targets were blamed for distorting clinical priorities, and in particular for one organisation achieving a target at the expense of another. For example, ambulances have been forced to queue up outside a busy emergency departments so that the ambulances might not be able to meet their target in responding to emergency calls, but the hospital can meet its A&E target. Excess emphasis on the targets can mean that other important aspects of care, especially those not easily measured, may be neglected. Some have however praised targets for producing faster reductions in waiting times in England than other UK countries between 1996 and 2006.
NHS England under the Conservative governments reduced the number of targets, in particular removing most of those relating to health inequality, and encouraged a system wide approach. However shortage of staff and funding meant that performance against targets nonetheless declined. Guidance published in February 2018 conceded that most of the targets would not be met before April 2019. The hospital care and A&E performance measures for October 2019 were the worst ever recorded.
Sajid Javid called for a ‘proper review of NHS targets’ in September 2021. According to Jeremy Hunt the Stafford Hospital scandal showed that concentrating on national targets led to managers deprioritising the safety and well-being of patients. Targets can benefit patients but they can also lead to bureaucracy, gaming and poor patient care, or as David Nicholson famously put it - "hitting the target and missing the point". But they are alluring to politicians. Hunt says the effectiveness of targets is in inverse proportion to their quantity and points out that no other country runs its healthcare system by targets. Goodhart's law applies: "When a measure becomes a target, it ceases to be a good measure".
National approaches
England
The NHS Constitution for England specifies waiting times in the accompanying Handbook, but does not provide a remedy should they be breached. Non-acute crisis response waiting time targets are to be introduced by NHS England for integrated care systems from April 2022.
Performance is to be measured on the percentage of services delivered within two hours. Mental health targets are also planned, although no start date has been set, requiring require that urgent referrals to community crisis services should be seen within 24 hours, and “very urgent” referrals should be seen within four hours. Mental health patients referred from emergency departments should be seen face-to-face by liaison teams within one hour.
Scotland
The Patient Rights (Scotland) Act 2011 establishes the treatment time guarantee, but also does not specify a remedy should it not be met.
Northern Ireland
Targets in Northern Ireland are set by the Health and Social Care Board and are less demanding than in the rest of the UK. None have been met since 2015, and some for considerably longer.
Wales Targets in Wales are set by the Welsh Government and set out in the NHS Wales Delivery Framework. The Welsh Government has taken a different approach to some areas of care, such as becoming the first nation in the UK to have a single waiting times target for cancer treatment. The Welsh NHS has broadly under-performed compared to the English NHS, with higher waiting times for both urgent and routine care. However a Full Fact report by the Chief Executive of the Nuffield Trust Nigel Edwards acknowledges that the two nations targets are not directly comparable because "the Welsh population is older, sicker and more deprived than the English population—so its NHS has to work harder".
Accident and emergency departments
A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. The original target was set at 100%, but lowered to reflect clinical concerns that there will always be patients who need to spend slightly longer in A&E, under observation. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, and admitted or discharged in under four hours.The Four Hour Target in Accident and Emergency The target was further moved to 95% of patients within four hours in 2010 as a result of the coalition's claims that 98% was not clinically justified. Trusts which failed to meet the target could be fined. In July 2016 NHS trusts were set new "performance improvement trajectories". For 47 of the 140 trusts with "type one" major A&E facilities this meant a target of less than 95% waiting under 4 hours. In January 2017 Jeremy Hunt announced that the target would in future only apply to "urgent health problems". In January 2018 only 77.1% of patients were admitted or discharged within four hours, the worst ever performance for type one A&E departments. In December 2018 it was reported that patients with only minor ailments could be excluded from the target and a new target introduced so the most urgent cases should be seen within an hour.
The effect of the target can be that patients waiting just below 4 hours get a lot of attention, but once the target is breached there is no further consequence. The average time spent by a patient in A&E who has breached four hours is around eight hours.
In January 2022 research published in the Emergency Medicine Journal found that there was one extra death For every 82 admitted patients whose time to inpatient bed transfer is delayed more than 6 to 8 hours from time of arrival at the emergency department.
New standards In May 2021, after prolonged consultation NHS England announced that the 4 hour target was to be replaced by a new set of 10 metrics. The new “bundle of ten standards” includes
Response times for ambulances Reducing avoidable trips (conveyance rates) to emergency departments by 999 ambulances Proportion of contacts via NHS 111 that receive clinical input Percentage of ambulance handovers (from ambulance to A&E) within 15 minutes Time to initial assessment — percentage within 15 minutes Average time in department — for non-admitted patients Average time in department — for admitted patients Clinically ready to proceed (time from when decision is made to admit or discharge, and patient is admitted or discharged) Patients spending more than 12 hours in A&E Critical time standards — aimed at ensuring the highest priority patients get care within a set timeframe such as an hour
In September 2022 Thérèse Coffey said: “I can absolutely say there will be no changes to the target for four-hour waits in A&E.”
Objective
The Labour government (1997-2010) had identified a requirement to promote improvements in A&E departments, which had suffered under-funding for a number of years. The target, accompanied by extra financial support, was a key plan to achieve the improvements. Prime Minister Blair felt the targets had been successful in achieving their aim. "We feel, and maybe we are wrong, that one way we've managed to do that promote improvements in A&E is by setting a clear target".BBC NEWS | Health | Target 'putting A&E care at risk'
48% of departments said they did not meet the target for the period ending 31 December 2004.BMA - BMA survey of accident and emergency waiting times, March 2005 Government figures show that in 2005–06, 98.2% of patients were seen, diagnosed and treated within four hours of their arrival at A&E, the first full financial year in which this has happened.BBC NEWS | Health | A&E success 'not sustainable'
The four-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labelling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.
Although the four-hour target helped to bring down waiting times when it was first introduced, since September 2012 (after the introduction of the Health and Social Care Act 2012 and top-down reorganisation of the NHS) hospitals in England struggled to stick to it, prompting suggestions that A&E departments may be reaching a limit in terms of what can be achieved within the available resources. The announcement of the reduction of the target from 98% to 95% was immediately followed by a reduction in attainment to the lower level.
Performance
By December 2014, the number of patients being treated within four hours had fallen to 91.8%. From December 2015, the 95% target over England as a whole was missed every month. From October–December 2016, only 4 out of 139 hospitals with major type 1 A&E departments met the target. In November 2018, the British Medical Association reported that performance on emergency admissions, trolley waits for more than four hours and A&E patients seen within four hours in the summer of 2017 was worse than in the winters of 2011–15. Performance against the four-hour wait target in the summer of 2018 was the worst second quarter performance recorded. Only 88.9% of patients were seen within four hours in September. The number of people admitted, transferred or discharged within four hours in emergency departments in September was up more than 3% compared to September 2017 with a 7% rise in emergency admissions said by John Appleby to be astonishing. Attendance at A&E departments has been increasingly steadily for many years, more so at ‘type 3’ departments, like urgent care centres (where waiting times are generally lower). In the first eight months of 2018, an average of 67,000 people attended each day. In January 2019, only 84.4% of patients were seen within four hours, the worst figure since the target was introduced in 2004. In November 2019 not a single A&E department hit the four-hour wait time target.
Performance in the first three months of 2019-20 was the worst since records began in 2011.
National A&E performance
Scotland In Scotland, the target is for 95% of A&E patients to be either admitted, transferred or discharged in four hours. It was last met in July 2017. Scotland has performed best on this measure out of the four UK nations, a position it has held since September 2015. However like all other UK nations this performance has recently declined. In Scotland this target has dropped 5% between May 2018 and September 2019.
England In England, the target is also for 95% of A&E patients to be treated, transferred, and discharged within four hours. However performance has fluctuated between 90 and 84% between 2015 and 2019, consistently putting it second in the United Kingdom. However performance against the target declined almost 10% between May 2018 and September 2019.