Changes to the payments trusts receive for A&E services have the potential to cause financial difficulties. The Foundation Trust Network’s benchmarking team worked with 17 trusts to pinpoint how A&E departments can stay on the right side of the new rules. FTN director Sue Slipman explains.

Focusing on accident and emergency is crucial - in England 3.36 million patients a year are admitted through A&E and many more receive treatment and return home. The coming changes in payments to trusts for their A&E work could cause real financial problems.

The Foundation Trust Network’s performance benchmarking of A&E services aimed to help NHS trusts compare their performance and find efficient ways of making better use of NHS funds.

Detailed information was collected relating to staffing and patients’ progress through A&E for two weeks in June 2010 as well as activity, cost and quality metrics for the financial year 2009/10.

Although the government has relaxed the four-hour A&E target (from 98 per cent to 95 per cent of patients), and this will be replaced by a new set of quality indicators from April this year, timeliness remains important. But there is currently no consistent set of measurements collected to assess A&E performance. 

The proposed spread of quality indicators means that A&E departments will need to balance priorities and take a patient-centred approach. It will not be so easy to tick the boxes once there are a large number of measures to consider.

Although many trusts collect a wide range of information on waits, clinical outcomes and patient experience, some trusts will have to collect additional data to demonstrate they satisfy all the new quality indicators.

The network’s benchmarking team, in partnership with McKinsey, worked with staff from 17 trusts to build an understanding of service organisation and costs through a detailed breakdown of activity in A&E.

A full and accurate picture of costs helps staff develop the skills to operate effectively within the national tariff framework.

Large variations

One significant finding was that A&E departments are likely to be costing most NHS trusts more to run than they receive in payments. In the study, A&E costs exceeded income for all but three trusts in 2009-2010, despite significant variation between trusts’ overall financial performance. The differences between A&E departments’ finances do not appear to be related to the number of patients seen in A&E.

The biggest driver of cost per attendance was staff costs. There was a two-fold variation in doctor and nurse costs between the highest and lowest cost trusts. There were also large variations in trusts’ diagnostic costs.

An additional financial pressure is that since April 2010 trusts will only be paid the full NHS tariff rate for admitted emergency patients up to the level of their 2008-2009 activity. For any extra admissions, they will receive just 30 per cent of the standard rate.  

Registration, triage and assessment processes remain a challenge. Benchmarking the 17 foundation trusts and aspiring foundations showed that patients waited, on average, 75 minutes from registration to initial assessment, regardless of the eventual outcome.

Patients who were discharged spent an average of just over two hours in A&E in total, while admitted patients remained in A&E for an average of three hours and 13 minutes.

On average, 13 per cent of mental health patients attending A&E remained for more than four hours. One of the actions to improve A&E departments that arose from the benchmarking was for trusts to establish suites designed specifically for mental health patients.

The four-hour breach rate rose progressively from 1.3 per cent for under 17-year-olds to 6 per cent for the over 85s. This effect is largely explained by the more complex and multiple conditions suffered by older people, which means they require specialist input or confirmed social service provision before a treatment or care plan can be finalised.

In many cases, admission of elderly or infirm patients can be avoided as long as social care can be arranged. As this will involve liaising with external agencies, it may involve the patient waiting in A&E before plans are finalised.

Redirecting patients to alternative care providers can be effective in ensuring that patients who really need the expertise available within A&E are seen more promptly. Some trusts have dedicated GP treatment areas or a GP surgery operating on the premises, or a minor injuries clinic.

A&E departments need the whole hospital organisation to work smoothly to improve their efficiency and cut patient waiting times. For example, if patients throughout the hospital are discharged early in the day, other patients can be admitted from A&E, reducing waiting times and freeing staff to treat other A&E patients. The network’s A&E briefing recommends that continuous monitoring and assessment of beds is conducted by a dedicated bed co-ordination team supported by a real-time electronic bed management system.

Trusts therefore face a triple challenge to make A&E work more efficiently.

They will, of course, have to demonstrate effective performance within A&E; but they will also have to achieve efficiencies across the whole trust, and they will have to ensure co-operation and co-ordination with social care organisations so patients receive the right treatment in the right place and are not admitted to hospital unnecessarily.