Four-hour A&E target moves closer to being scrapped

Author: Ingrid Torjesen

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NHS England has announced pilots to test a range of measures to assess NHS performance including alternatives to the four-hour A&E waiting target as promised by the NHS Long Term Plan.

Standards to be trialled include a rapid assessment measure for all patients arriving at A&E, coupled with faster life-saving treatment for those with the most critical conditions, such as heart attacks, sepsis, stroke and severe asthma attacks.

In a move to improve mental health care, one standard will assess whether patients arriving at A&E experiencing a mental health crisis receive emergency care within one hour.

A new measure of time will aim to provide an overview of hospital performance by recording how long every patient spends in A&E, so an average can be calculated, and any long waits will be evident. The use of average waiting times is based on the success of new ambulance standards, which have seen average waiting times for the most urgent calls improve by 14% over the last year, despite an increasing number of call-outs.

It is proposed that rules on reporting prolonged waits for those who need to be admitted to a ward will also be strengthened, including reporting the most serious cases to the Care Quality Commission as a patient safety concern.

Other new measures being field tested under the proposals include ensuring a definitive diagnosis is provided to patients within 28 days of urgent referral by their GP or a screening service for suspected cancer.

Dr Nick Scriven, president of the Society for Acute Medicine (SAM), said: “Back in 2016, SAM made loud and clear calls for the NHS to stop aiming only to meet the four-hour standard when it was clear a whole system approach was required. The review of the target is an opportunity to focus on a range of patient outcomes and quality standards to measure pressures and take effective action earlier.”

Around a fifth of all emergency admissions from A&E currently occur in the final 10 minutes before the four-hour deadline, suggesting that hospitals are being driven to focus on the target, rather than what is the best approach for each patient.

Dr Chaand Nagpaul, British Medical Association (BMA) council chair, said: “The BMA has consistently believed that arbitrary targets can result in unintended impacts on patient care, especially when they are linked to funding.  For example, when the health secretary reinterpreted the four-hour A&E target in 2017 to include only urgent cases, rather than all attendances, there were concerns that NHS managers simply redefined what cases are ‘urgent’ so that the target can be met and resources secured.”

He added: “Enabling vulnerable patients with mental health issues to gain easier access to higher standards of care is an encouraging focus of today’s announcement and long overdue.”

Professor Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “The four-hour A&E standard has been valuable in focussing efforts on improving emergency care but if we are to continue to improve patient safety and ensure every patient gets the priority they individually need it must be reformed and we must find better measures to ensure patient safety.

“Emergency departments need a set of standards which gives priority to patients with life-threatening conditions, ensures people get care in a timely way and puts pressure on the whole hospital to end long corridor waits for those who need admitting. We are confident that field testing these proposals is the safest and most effective way of improving care.”

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: “We know from many years of experience that, when implemented correctly, targets can be beneficial for the care patients receive from the NHS. To ensure that all targets are realistic and in the best interests of patient care at that time, it is sensible that they are regularly reviewed, and where appropriate, that alternatives are explored, tested and thoroughly evaluated to ensure that the care patients receive is always improving.”

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