Since the introduction of the A&E access standard 15 years ago, there also have been major changes in the practice of medicine and the way urgent and emergency care services are delivered, for example: the introduction of specialist services for stroke care and the creation of trauma and heart attack centres. Given that models of care have changed and will change further, the NHS Long Term Plan explains that the headline access standards need to reflect these changes and encourage behaviours that support the new models care.
Proposals to cut the four hour target for 95 per cent of A&E patients to be admitted, transferred or discharged were trailed recently as one of a number of proposals that will be piloted from April with a wider roll out from autumn 2019 and then full implementation from April 2020.
The review which is being led by NHS National Medical Director, Professor Stephen Powis, comes at a time when the A&E performance against the four-hour wait has fallen to its "worst ever" level according to NHS England data.
Commenting on the figures, President of the Royal College of Emergency Medicine, Dr Taj Hassan said: “We fear that these figures will give impetus to move away from meaningful measurement of flow and system performance, which if not managed carefully runs the risk of hiding problems. We look forward to working with NHS England on their new standards of measuring quality to ensure that this does not happen, and that patient safety and care continue to be paramount.”
Emergency medicine doctors and doctors from other royal colleges have struggled to agree on the axing of the four hour target, with many emergency physicians urging the Government not to abandon the metrics warning that such a move would harm patients. The Royal College of Emergency Medicine has issued a position statement on a series of complementary metrics to supplement the four hour target – but put simply, the college believe that the four hour standard should be retained.
NHS England’s emergency care clinical lead has meanwhile said that there should be “zero per cent tolerance” on patients spending longer than six hours in an accident and emergency department, suggesting a need to reflect greater demand, whilst retaining the principle.
Whilst there appears to be no consensus around the proposed changes, it is worth remembering that almost nine years have passed since Andrew Lansley, then Secretary of State for Health, confirmed that the four hour waiting time standard in A&E should be abolished from April 2011. Lansely’s letter to John Heyworth, the then President of the Royal College of Emergency Medicine, says that the A&E target is a “process target” that does nothing to ensure that patients are receiving the highest quality care and that “it is time to take a more balanced approach to ensuring the quality of care provided by A&E departments”.
The current proposals are clearly not going to be as drastic as Lansley’s (abandoned) proposal – but whilst ever there is a ‘time’ target there will be a risk that a patient is treated by reference to the clock rather that their clinical presentation.
…plus c'est la même chose?
Duncan Astill, Partner
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