> Next month we are going to be assessed viz the 4 hour
> targets.  I suspect we will pass with over 90% compliance as
> the powers that be will cram even more beds into the unit,
> including my office.

The definition of 'bed' is open to debate. However, it does mean an area
with a reasonable level of comfort, privacy etc. Have you written to your
medical director, chief exec, trust chairman, PCT, local patient/ hospital
user representative bodies, local newspaper, MP, David Lammy etc. to express
your view that trolleys in minors don't fit the definition of 'bed'?

I've no published evidence to support this, but it seems to me that keeping
other specialities out of A and E has more influence on waiting times and
perception of how busy you are than level of staffing.
Unfortunately, inpatient specialities tend to like A and E departments that
hold onto their patients for them, and find it easier for patients to be
clerked in, worked up in A and E. If you put a stop to this, you will find
yourself involved in a certain amount of debate.
Looking around our region, the A and E consultants who do or did not allow
other specialities into their department (other than seniors by special
invitation and for specific tasks) tend to command more respect than
affection from inpatient specialities, but their departments run a lot
better than would be expected from funding levels. Basically you've got to
be pretty aggressive about it and put your foot down. Don't allow SHOs in
other specialities into your department, don't do the SHO work for them- if
you allow only consultants into your department and do only the minimum
work-up needed for treatment needed in the department, they get better at
finding beds for their patients. But don't expect too many Christmas cards
the first couple of years.

> How can we take a target such as these 4 hours
> seriously when
> no-one has even CLAIMED to have evidence of any benefit to
> patients or staff
> or the NHS from setting such a limit. Certainly, I have not
> heard even ONE
> positive benefit comment on this list.

The 4 hours is a reasonable compromise between what is ideal (moving to a
more comfortable area as soon as the need is identified) and the achievable.
Door to ward time is taken instead of decision to admit to ward time because
its harder to fiddle (some places were taking 3 days to decide to admit).
The benefits of moving a patient to a ward are obvious: more comfort and
privacy; proper beds so less risk of pressure sores (and resulting prolonged
stay), A and E staff freed up to deal with A and E patients etc. The
administrative benefit to A and E is that it gives us a tool to allow us to
get patients out of the A and E department (rather than having other
specialities refusing to accept them for admission until they'd seen them
and not seeing them) without having to be so pushy about it.

Matt Dunn
Warwick


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