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Reshaping A&E waiting times: the sector reacts

Reshaping A&E waiting times: the sector reacts
By Valeria Fiore Reporter
12 March 2019

NHS England announced yesterday that it will start testing new waiting time standards across a number of sites over the coming months.

The intention is to formally introduce the new standards from April 2020 – if the feedback and the results from the trials are successful.

NHS England explored alternatives to the four-hour A&E waiting time target after saying in an interim report on NHS access targets that there are ‘well-documented issues’ with the flagship target.

Introduced in 2004, the target hasn’t been met since 2015.

Here is what the healthcare sector has to say following the proposals that bring the NHS one step closer to scrapping the controversial target.

‘Greater culture of openness’ needed

BMA council chair Dr Chaand Nagpaul 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.

A recent BMA survey found that 77% of doctors agreed that “national targets and directives are prioritised over quality of care” and 74% agreed that “financial targets are prioritised over quality of care”.

‘We must ensure that any change to the target system is accompanied by clear, unambiguous measures to increase transparency – and not reduce accountability or information about how well care is delivered.

It is vital that the piloting of new standards create a greater culture of openness where we have a true picture of the experience of patients and the challenges facing our health service.

The BMA will be examining the detail of these proposals in order to guarantee that the public has the ability to hold the government to account.’

‘Powerful tools’

The King’s Fund chief executive Richard Murray said:

‘NHS waiting times standards are powerful tools that have played a key role in improving the experience of patients. But these targets have also resulted in some unintended consequences and many of them were developed well over a decade ago – so it is right to consider whether they are still fit for purpose.

‘It is right to pilot the proposed changes to A&E and planned hospital treatment to understand their impact on patient safety and the quality of care.

However, these targets have not been met for several years and continue to be missed by a wide margin so it is important to be realistic.

Changing existing targets and introducing new standards is not a panacea for improving patient care – without enough staff and resources to care for patients, targets both new and old will continue to be missed.’

‘Vital to ensure process is clinically led’

NHS Providers deputy chief executive Saffron Cordery said:

‘The key NHS targets have played a valuable role in improving access to care and have become a widely recognised indicator of NHS performance but clinical practice moves on so it is right to consider whether they remain relevant and reflect best practice.

’In order to win public confidence, it will be vital to ensure this process is clinically led and that any changes have been carefully tested and evaluated.

‘Ultimately, the decision to change the constitutional standards will lie with politicians but it must be informed by clear and compelling evidence on best clinical practice – and driven by what is in the best interests of patients and service users.’

Current target and ‘perverse incentives’

Dudley CCG chief executive Paul Maubach said:

‘At the time the four-hour A&E target was introduced 15 years ago it was an extremely important and necessary measure. However, we now have much more sophisticated routine information about the performance of our A&E departments compared to then, so why would anyone not want to take advantage of this?

It is entirely sensible, in fact necessary, that NHS England reviews how we evaluate the effectiveness of our A&Es based on the most up-to-date information.

‘NHSE’s report also highlights what we already know: that the target can lead to perverse incentives for hospitals’ processes influencing some admissions or discharges in the period immediately before breach. Any move to put clinical judgement first, covering the whole pathway of care, has to be welcomed.

‘Most importantly, in all of our local public engagement on this issue the message from the public has always been clear: when there is a true emergency, they need the service to be there for them and to be able to respond – by making sure the initial triage is right and ensuring that the most complex cases can be seen quickly. The four-hour target is, by itself, insufficient to evidence this.’

‘Enhance and refine the four-hour standard’

President of the Royal College of Emergency Medicine Dr Taj Hassan said:

‘While we are dismayed by many of the myths being pedalled around the four-hour standard, we are keen to ensure that any changes are not imposed due to political will but are developed responsibly, collaboratively and are based upon clinical expert consensus in the best interests of patients.

‘The measures set out in this document are what we believe are in the best interests of patients and will enhance and refine the four-hour standard as a powerful system measure of flow.

These have been developed based on the expert opinion of clinicians working in emergency medicine and are supported by a range of colleagues from other specialties.

We also note that the last multidisciplinary evidence-based review in Scotland by Sir Harry Burns in November 2017 clearly stated that the four-hour standard should be retained.

‘We note the Prime Minster made a commitment to involve clinicians in the development of new standards. While we have been disappointed to not have been involved from the outset of this process, and that there has been little clarity around who has been involved, we now look forward to providing our clinical expert advice to NHS England and NHS Improvement to assist them in their review.’

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