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NHS England edges closer to discarding four-hour A&E target


By Valeria Fiore
Reporter
11 March 2019

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NHS England today moved one step closer to scrapping its flagship A&E target, under which patients should be seen within four-hours of arrival.

Under the proposals, announced today as part of an interim report on NHS access standards – NHS England said the four-hour standard only offers a ‘limited insight into patient care’.

The report, led by NHS England medical director Professor Stephen Powis, added that alternative options ‘are worth exploring’.

NHS England set out five proposed access standards for urgent and emergency care. These will be trialled along with other proposal concerning cancer, mental health and elective care in the coming months, across a number of sites that will be selected by NHS England.

Following the results of these trials, the proposals could be mandated across the NHS from April 2020, according to NHS England.

Five proposed new targets

The interim report suggested that patients with life-threatening conditions should receive care within one hour or arrival. This includes patients suffering from stroke, heart attack, sepsis, acute severe asthma, and mental health crises.

All patients should receive timely initial assessment when arriving at A&E, according to the report, which says this will help ‘focus on patient safety prioritisation and streaming to the most appropriate service’.

The report added that the average waiting time should be tracked for all patients visiting A&Es and that rules on ‘reporting prolonged trolley waits for admission’ should be strengthened.

As part of the proposals, hospitals are also being encouraged to use same day emergency care, which will be available to every major hospital next winter to prevent avoidable overnight admissions, Professor Powis announced last week.

NHS England also suggested that all patients should receive a rapid response when calling NHS 111 and 999 and should be referred to the service that best meets their needs.

Controversial four-hour target

The four-hour A&E target has been in the spotlight since NHS England chief executive Simon Stevens in January told Radio 4 Today’s programme that ‘faster standards’ could replace the target.

The Royal College of Emergency Medicine (RCEM), which was dubious about who the ‘top doctors’ were that Mr Stevens referred to as advocating for the target to be scrapped, said that abandoning the target would have a ‘catastrophic impact on patient safety’.

Introduced in 2004, the target hasn’t been met since 2015, with RCEM tracing this back to scarce resources and inadequate staffing levels.

According to NHS England data published in February, A&E performance against the four-hour target reached its worst level in 15 years in January, with only 84.4% of patients assisted within four hours of arrival across all A&E departments, against the 95% target.

Commenting on the proposals, RCEM president 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.

‘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.’

CQC chief inspector of hospitals Professor Ted Baker 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.’

NHS Confederation chief executive Niall Dickson said: ‘This package of reforms is needed – it should help front-line staff focus on caring for the patients with the most critical needs.

‘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.’

The King’s Fund chief executive Richard Murray said that changing these targets is ‘not a panacea for improving patient care’ and new targets will continue to be missed without appropriate funding for staff and resources.

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