Editorial: A&E targets lift efficiency but should never rule

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Targets can be a tricky matter, and not just for those who must meet them. They can be of little use if they are not well defined and the figures associated with them present an incomplete picture.

Equally, they can be accorded too much importance. In the case of targets placed on hospital emergency departments, critics say this may lead to the treatment of a broken finger receiving as much priority as a life-threatening heart problem.

Nonetheless, the results of the Government's target for 95 per cent of patients to be admitted to a ward, discharged or transferred from an emergency department within six hours have been largely rewarding.

The latest quarterly figures for the target, introduced by Health Minister Tony Ryall in 2009, show overall compliance by district health boards sits at 93 per cent. While Waitemata, Counties Manukau and Auckland have met or surpassed the target, others, including Waikato and Capital & Coast, are struggling. But the overall figure is up from 92 per cent a year ago and, most importantly, a jump from 80 per cent when the target was established. Dr Tim Parke, the former chief of the emergency department at Auckland City Hospital, estimated that meeting the target saved about 200 lives nationally each year, including a double-digit number at Auckland.

The target serves other purposes, not least providing a higher degree of public accountability. But the system's success needs to be qualified.

The six-hour figure does not record the actual time a patient can expect to sit waiting to be assessed and treated. It is is the total time spent in emergency, which, with time spent waiting for the effect of medications to be monitored and so on, can distort the true benefit of a six-hour target. Waiting for an initial appraisal and care is the particularly nervous experience, and it is the real waiting time that needs to be kept to the minimum possible.

Another qualification is that such targets can encourage gaming of the system. Some larger hospitals have created short-stay units in their emergency departments that are used, for example, to observe drug-overdose patients until they can go home. Some have also installed assessment and diagnostic units beside emergency departments to take stable patients referred by a GP who may start treatment before having surgery, going to a ward or being discharged.

Patients moving from an emergency department to such units are considered to have been admitted, so the six-hour clock stops. This gives an added incentive for these units although, in medical terms, they can certainly be justified. However, in Britain, which has a more stringent four-hour clock, gaming is far more widespread. Patients have been left to languish outside emergency departments to meet the target, with fatal consequences.

This has not stopped Western Australia following Britain's lead, and this country should follow suit if the 95 per cent target comes to be regularly met. But this should not be done prematurely. Experience in Britain suggests the perils of unrealistic targeting extend beyond gaming. Figures released in December showed patients were having to wait longer to be treated than four years earlier. One in three also claimed to have spent more than four hours in emergency departments. Clearly, the drive to meet a target was not ensuring good patient care. Too often, also, the sickest patients were not the top priority.

Waikato Hospital says it will not compromise on quality of care or risk patient death to comply with the New Zealand target. Its approach is right. Targets have a proven ability to increase performance, but they should never become the be-all.