National Emergency Access Target: aiming for the target but what about the goal?

What is the problem? Australia has seen increasing demand on hospital Emergency Departments (ED) with a 65% rise in presentations between 2001 and 2011 (McCarthy 2013) resulting in increased waiting times, prolonged stays, overcrowding and delayed admission (Geelhoed and de Klerk 2012). Prolonged ED stays can adversely impact patient outcomes (Maumill et al. 2013; Sullivan et al. 2014; Sullivan et al. 2015; Sun et al. 2013) leading to increased length of hospital admission and higher mortality (Braitberg 2012; Forero et al. 2010; Green 2014; Mountain 2010). What was the response? The National Emergency Access Target (NEAT) was adopted across Australia in 2011 under the premise that spending less than 4 hours in the ED would improve patient care. NEAT used a single time based target to incentivise patient flow through ED with the eventual goal that 90% of patients presenting to the ED would be discharged, transferred or admitted within 4 hours (COAG 2011). The target mirrored the United Kingdom’s 4-hour rule, although concerns have been reported about cost, data manipulation and limited impact on quality improvement (Weber et al. 2012). What does the evidence say? Despite improvement in NEAT attainment, hospitals broadly have been unable to achieve the targets particularly for admitted patients, the intended beneficiaries of the policy. NEAT has resulted in increases in hospital admissions (Goh 2012; Lowthian et al. 2015), potentially adding to access block and reducing patient flow (Perera et al. 2014) with reports of prioritising patients as they approach 4-hours (Green 2014) and data manipulation (ACT Auditor-General’s Office 2012). Implementation of NEAT through a single incentivised process indicator presents risks to healthcare quality, appropriateness and safety (Baggoley et al. 2011; Mason et al. 2012; McCarthy 2013; Nicholls 2015; Weber et al. 2011), with potential for inadequate assessment and treatment due to rushed decision-making (Mountain 2010). What does this mean for health service leaders and policy makers? Reform using a single, incentivised, process-based mechanism is unlikely to achieve broad changes to the effectiveness, safety, quality and equity of care provision, and risks producing unintended consequences. It is for these reasons that the NEAT policy at present cannot be considered a complete success