Proposals have been revealed to scrap the blanket four-hour access target in accident and emergency departments in favour of a new approach that prioritises the most acutely unwell patients.
The draft reforms have today been put forward by Professor Stephen Powis, who is leading a government-ordered review of current waiting time measures in England’s NHS services.
“We must find better measures to ensure patient safety”
The suggested changes have been laid out in an interim report by Professor Powis and will now be trialled in practice across pilot sites over the coming months.
These include ditching the requirement on A&E departments to either admit, transfer or discharge near enough all patients within four hours of their arrival.
Instead, units will be expected to focus on delivering “rapid” assessment of patients after they turn up for care and prioritise treatment for those with the most serious conditions.
A new one-hour treatment target will be introduced for patients with life-threatening problems including stroke, heart attack, major trauma, sepsis and severe asthma.
In addition, patients who arrive at A&E in a mental health crisis will receive emergency care from a liaison psychiatry team within one hour.
Professor Powis, NHS England’s national medical director, notes in his report that the current standard does not measure the total amount of time patients wait in the emergency room beyond four hours.
“The standards will assure patients that they will be seen quickly”
For example, a patient who waits four hours, five minutes will be considered a breach in the same way as another patient who waits 12 hours.
Departments will therefore be tasked with recording the entire length of wait of every patient in a bid to stamp out “hidden waits” – with performance assessed on the mean wait for all attendees.
The proposals draw on polling of more than 2,000 people conducted by watchdog Healthwatch England in January, which found that 79% of respondents thought it was very important to prioritise patients by urgency – more than double the number who placed the same importance on admitting or discharging people within a set time (38%).
Three in every four (75%) of those who responded also said they thought it was very important that people should be assessed quickly when they arrive at A&E.
Professor Powis highlighted in the report that the current standard was “actually not well understood by the public” with many believing four hours was the time for a patient first to be seen, rather than for their treatment to be completed or to be admitted, transferred or discharged.
The proposals will also strengthen rules on reporting prolonged corridor waits on trollies for patients who need to be admitted to a ward, including reporting the most serious cases to the Care Quality Commission as a patient safety concern.
“We will need accurate and honest feedback from the pilots”
Professor Powis said the report: “The public are most concerned with time to be seen, and want to know that the sickest patients are prioritised.
“By measuring time to assessment, the standards will assure patients that they will be seen quickly; and much quicker than the four hours they often believe they will have to wait to be seen,” he added.
“Then, the standards will measure whether those with the most life-threatening conditions are beginning their treatment quickly,” he said.
The report does not say if A&E departments will be required to assess patients within a certain timeframe.
Trusts will also be incentivised to provide same day emergency care where appropriate, which means patients are seen and treated within 24 hours, avoiding an overnight - a priority area included in the NHS Long Term Plan.
Professor Powis said in the report: “With the move to same day emergency care, a four-hour ‘admission’ cut-off is, for an increasing number of patients, clinically meaningless.
Dame Donna Kinnair
“Maintaining a singular focus on the four-hour target could penalise the very departments who are making the most progress towards same day emergency care,” he added.
These A&E standard reforms will sit hand-in-hand with new response targets for the 111 NHS advice line.
Meanwhile, the review proposes a new faster 28-day wait for a cancer diagnosis following an urgent referral.
Professor Powis is also calling for current cancer wait targets to be simplified.
Under the proposals, patients will have to wait no longer than 62 days for their first treatment from an urgent referral from a GP practice or NHS cancer screening service.
All cancer patients will face a maximum 31-day wait to receive care from a decision to treat.
Dame Donna Kinnair, acting chief executive of the Royal College of Nursing, expressed her support for the proposals but said it was “hard to see” how the new standards would be met without more staff.
“We will need accurate and honest feedback from the pilots to ascertain whether it is possible to roll out these measures nationally with the huge workforce gaps we currently have,” she said.
Professor Ted Baker, chief inspector of hospitals for the CQC, has backed the changes to the A&E four-hour standard.
edward ted baker
“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,” he said.
“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,” he added.
The clinically-led review of standards was announced by prime minister Theresa May in June 2018 alongside additional investment in the NHS.
Professor Powis has been working with clinical leaders including senior nurses to work out how targets should be amended to reflect significant advancements in practice.
The proposals will be trialled in a number of areas across England in the coming months.
Evidence from the test sites will be evaluated and used to inform final recommendations later in the year, with the updated standards being implemented from April 2020.