The new accident and emergency indicators will require some departments to double their A&E consultants while others will struggle to record the data without upgrading their IT, the HSJ has been told.

Eight new “clinical quality indicators” were announced by health secretary Andrew Lansley this week to replacement to the single four hour A&E target. Under the old target hospitals had to ensure 98 per cent of patients completed their A&E visit within four hours. That target – or “indicator” – is still maintained, although the proportion of patients it applies to will be relaxed to 95 per cent from 1 April.

Seven other indicators have also been added (see below). They include the proportion of people leaving A&E without being seen and the time between a patient’s arrival to the start of their full initial assessment.

College of Emergency Medicine president John Heyworth said the measures of “timeliness and quality” were a good combination and would improve patient care.

He said: “A single measure of time didn’t equal quality…[the indicators] raise the stakes but it has to [lead to an] expansion in emergency consultant numbers.”

The college wants to see ten whole time equivalent emergency consultants in every A&E department.  There is currently an average of four and a total of 940 across the country responsible for 18 million patients a year. The college wants this increased to 2,250.

Mr Heyworth, who is an A&E consultant at Southampton General Hospital, added: “Without that expansion it will be almost impossible to achieve sustained compliance as required and as expected.”

He said there were also issues around IT and trust abilities to collect data as IT provision was “very variable” between departments. The DH insists the indicators are not targets but each indicator has a so called “bottom line” or minimal standard which, according to the implementation guidance, trusts “need to be taking into account”.

The guidance goes on to state that the bottom lines should be used with “caution” and the indicators should be viewed as a whole set.

Mr Heyworth added: “Five of the indicators will be measured by the DH performance management team. That’s clearly important because that really gives these indicators teeth.”

NHS Confederation deputy policy director Jo Webber told HSJ it would be impossible to measure outcomes without using targets.

She said: “People will still be reporting their four hour waits, albeit in a different format. Outcomes are never going to be completely without process targets as part of them.

“Some process targets are good proxies for outcomes.”

The ambulance service category B target which requires trusts to reach serious but non-life threatening cases within 19 minutes 95 per cent of the time is also to be scrapped in April and replaced with a set of 11 clinical indicators due to be published early next year.


IndicatorBottom line
Percentage of A&E attendances for cellulitis and deep vein thrombosis that end in admission60 to 90% of cellutitis and 90% of DVT patients to be treated through ambulatory care rather than admission
Unplanned re-attendance at A&E within 7 days of original attendanceTo be held between 1% and 5%. Below 1% may suggest undue risk aversion; above 5 % may trigger intervention*
Percentage of people who leave the A&E department without being seenBelow 5%. Above many trigger intervention*
Total time spent in the A&E department
A 95th percentile wait above four hours may trigger intervention*. Single longest wait should be no more than six hours.
Time from arrival to start of full initial assessmentGood practice would have all patients assessed within 20 minutes. A 95th percentile above 15 minutes may trigger intervention*
Time from arrival to start of definitive treatment from a decision-making clinicianPatients should be seen within 60 minutes but this may be too long for serious cases. A median above 60 minutes may trigger intervention*.
Percentage of certain high risk patients presenting at type 1 and 2 A&E departments reviewed by an emergency medicine consultant before being discharged.All these patients being seen by a consultant would be good practice but sites not able to reach this should aim for continuous improvement.
Qualitative description of what has been done to assess the experience of patients using A&E services, their carers and staff.Cannot “be restricted to reporting quantitative measures of patient satisfaction from questionnaires”.

*a headline measure in the operating framework