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NHS England shakes up A&E targets

NHS England has confirmed a range of proposals to overhaul rapid care measures, including the current Accident & Emergency four-hour waiting time standard. 


A raft of proposed clinical improvements aim to deliver rapid assessment and treatment for patients with the most serious conditions and expand short waits for millions more NHS patients.


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, is one of the proposals. In addition, patients arriving at A&E experiencing a mental health crisis should receive emergency care within one hour. 


A new measure of time in emergency departments will also be tested, with the aim of ending hidden long waits and providing a more accurate view of hospital performance by recording how long every patient spends in A&E, not just whether their discharge or admission time breached the target.


This could prevent tens of thousands of unnecessary hospital admissions each year by improving upon the current four-hour ‘cliff edge’ target.


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


In addition, the proposals will strengthen rules on reporting prolonged waits for those who need to be admitted to a ward, including reporting the most serious cases to the Care Quality Commission watchdog as a patient safety concern.


The four-hour A&E waiting target was introduced in 2004 and it was successful in helping to reduce lengthy waits faced by many patients. However, performance against this target has been under pressure. The latest A&E Attendances and Emergency Admissions figures (for January 2019) revealed just 84.4% of patients were seen within four hours - the lowest percentage since this data collection began.


Last year, the Prime Minister requested a review of the four-hour standard alongside other measures.


Professor Stephen Powis, National Medical Director of the NHS in England and leader of this review, says: “Now is the right time to look again at the old targets which have such a big influence on how care is delivered, to make sure that they take account of the latest treatments and techniques, and support, not hinder, staff to deliver the kind of responsive, high-quality services that people want to see.”


Dr Nick Scriven, president of the Society for Acute Medicine (SAM), adds: “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.”


Niall Dickson CBE, Chief Executive of the NHS Confederation, says: “Targets matter - they can concentrate minds and have helped provide faster access to care for millions of patients. They helped eliminate long waits in the 2000s when patients were waiting up to two years for inpatient treatment and up to 12 hours in A&E. This had to change and, backed by more staff, funding and focus, the NHS achieved great things for patients. But targets are blunt tools, and some need to be refined in an era where patients have more complex needs.


“This package of reforms is needed - it should help front-line staff focus on caring for the patients with the most critical needs. And it will help reduce some of the challenges we see now – for example in A&E staff are under enormous pressure to admit patients just ahead of the four-hour limit even when this is not necessarily the clinical priority at that moment.


“This is a more nuanced approach, but we must not lose sight of the importance of making sure patients have fast access to care. What matters is that changes are based on sound evidence on their impact on patients and staff. That is why we welcome the plan to pilot these changes in some areas and test their impact before any final decisions are made to roll them out across the NHS.”


The test areas, which are to be confirmed, will assess performance against the following criteria:


* Promote safety and outcomes

* Drive improvements in patient experience

* Are clinically meaningful, accurate and practically achievable

* Ensure the sickest and most urgent patients are given priority

* Ensure patients get the right service in the right place

* Are simple and easy to understand for patients and the public

* Do not worsen inequalities.


Implementation of the new standards will begin from April 2020.


Stephen Powis has also confirmed that every major hospital will provide urgent same day services to improve care for patients and cut unnecessary admissions by next winter.


Many hospitals are already providing comprehensive care without admitting patients who come to A&E with conditions such as pneumonia or other breathing difficulties through same day emergency care (SDEC) services, which are also known as ambulatory care.

SDEC services can prevent patients deteriorating from unnecessary or long stays in hospital, free up beds in hospital wards, and improve the flow of patients through A&E - allowing doctors and nurses to focus on those who need the most urgent care.

But clinical leaders believe that around half a million more patients a year across England could be assessed, diagnosed, treated and allowed to return home without the need for an overnight stay.

From Spring, local pilots will test how new NHS standards for urgeny and emergency care could support the ambition to ensure patients across the country benefit from this service, with hospitals to be measured on their success in reducing overnight admissions.


As part of the NHS Long Term Plan, all hospitals which have a full Emergency Department will be required to step up efforts to ensure that they provide this service, with the aim of a third of patients who require an emergency admission being able to return home the same day, up from a fifth currently. The full adoption of SDEC services will help ensure that people with urgent care needs get the right help in the right place and reduce pressure on A&Es.


Click here to read the review.