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The 14 trusts piloting new accident and emergency standards have finished the first phase of the trial, which could pave the way for the four-hour target to be ditched. So, what have they learned so far?
If you need a quick recap of where the NHS’ clinical review of standards trial of new urgent and emergency care targets is up to, see the box below for a refresher.
NHS England’s ban on pilot trusts discussing the trial (“the first rule of the standards review club, is you do not talk about the standards review club”, to coin a phrase) means there are no official documents or comments to analyse.
But the feedback I’ve had from several senior figures involved can be split into five categories:
1. Debate around which “life threatening” conditions should be subject to new rapid ‘one hour or less’ targets;
2. A lack of clarity around the benefits of measuring the mean time in A&E;
3. The technological barriers;
4. The new 12-hour metric laying bare the true number of long waiters;
5. The pace of the study means it is being developed on the fly, but local figures within the study report constructive discussions with their national counterparts.
Quick refresher: where the A&E standards trial is up to
NHS England’s clinical review of standards, published in March, set out plans to trial a range of new emergency care waiting time standards.
The trial could pave the way for the abolition of the NHS’ most important performance measure, the four-hour standard.
Proposed new standards include the average (mean) time for patients waiting in A&E; time before a patient is clinically assessed; and then how long the most critically ill patients wait (eg: stroke and heart attack patients).
The 14 trusts involved in the trial recently finished the first of two six-week testing periods. They are now awaiting further guidance on what to test in a second six-week period, which will commence in the coming weeks.
The new ‘first hour’ targets
The debate around which “life threatening” conditions should be subject to rapid one hour or less targets was always going to be complex, and it remains live.
These new treatments within the first hour targets will be trialled by the pilot trusts when the second phase starts in the coming weeks. As revealed by HSJ today, plans to trial a new one-hour sepsis target, which were in the standards review in March, could be dropped.
Senior sources told HSJ that performance managing how quickly the NHS reacts to cases of the complex condition was still a major priority, but it could instead be subsumed into a broader “physiological derangement” metric.
You can read more about how that could work here. Several senior clinicians told HSJ subsuming sepsis into the broader metric “made clinical sense”.
HSJ understands conditions being considered are heart attacks, strokes, major trauma, physiological derangement and severe asthma. Further changes have not been ruled out.
Giving the mean time real meaning
The target which systems leaders seem most enthusiastic about is the average (mean) time patients spend in A&E.
The idea is to have the mean time that patients are spending in the ED displayed in real time on a screen visible to the department’s staff.
Such a metric may well have benefits but clinicians told me it will be relatively meaningless unless it is disaggregated and broken down into mean time for admissions and non-admissions.
A senior source told me: “At the moment they are aggregating the time spent by admitted and non-admitted patients in the department.
“I think you need to disaggregate the admitted and non-admitted data because admission rates vary so significantly. Some trusts admit less than 20 per cent and others more than 40 per cent. We know admitted patients are more complicated and take longer so a combined mean time is not a fair comparison. It would be utterly meaningless.”
The first six-week trial completed in May was predictably hampered by problems with some IT providers either unable or unwilling to adapt systems to assist the display of the measurement of the new metrics.
HSJ was told by multiple sources that trusts with IT systems provided by large US providers, such as Cerner and Epic, have had problems adapting their systems to show “patients’ mean time in A&E” in emergency departments.
Sources told HSJ trusts with “more agile systems”, such as those being used in Poole and Rotherham, have managed to get this up and running.
NHSE sought to play down concerns around technology. A spokesman told me: “There haven’t been any unexpected or unresolvable problems with the IT side of things, and all suppliers have engaged constructively.”
But clearly the category of “expected technological problems” for a trial such as this is a big one. Getting the tech side of things sorted will continue to be a significant challenge (as it always is in NHS-land).
Twelve hours now means 12 hours
The clock for the existing 12-hour metric currently begins once a decision has been taken to admit the patient, so it neglects the time the patient has been waiting before then.
Trial sites have been instead measuring 12-hour waiters from the front desk, starting the clock at the same place they do for the four-hour target.
This makes far more sense but, suffice to say, it means there are a lot more 12-hour breaches. The measure, however, gives a far more accurate and honest reflection of a department’s performance.
While trusts may wince at the numbers in the short term, there is consensus that this is a move in the right direction.
Many senior trust chiefs, senior clinicians and think tank figures have expressed exasperation and dismay around how such a critical trial is being carried out at breakneck speed and out of public view.
It would be unfair to expect NHSE to give a running commentary on the trial, and keeping the trial data under wraps is eminently sensible. But the lack of transparency and engagement with the wider NHS community remains a valid gripe.
However, there is some good news around engagement. Local sources reported to me that discussions with national leaders have been constructive, and that they were being listened to by their national counterparts.
Of course, the proof of the pudding is always in the eating, and whether constructive discussions turn into tangible actions remains to be seen.
The 14 trusts field testing the new A&E metrics
|Luton And Dunstable University Hospital Foundation Trust|
|North Tees And Hartlepool Foundation Trust|
|Chelsea And Westminster Hospital Foundation Trust|
|West Suffolk Foundation Trust|
|Poole Hospital Foundation Trust|
|Imperial College Healthcare Trust|
|Frimley Health Foundation Trust|
|The Rotherham Foundation Trust|
|Cambridge University Hospitals Foundation Trust|
|Mid Yorkshire Hospitals Trust|
|Kettering General Hospital Foundation Trust|
|University Hospitals Plymouth Trust|
|Portsmouth Hospitals Trust|
|Nottingham University Hospitals Trust|
Information obtained by HSJ
- Acute care
- CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST
- CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST
- Emergency care
- FRIMLEY HEALTH NHS FOUNDATION TRUST
- IMPERIAL COLLEGE HEALTHCARE NHS TRUST
- KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST
- Luton and Dunstable University Hospital NHS Foundation Trust
- MID YORKSHIRE HOSPITALS NHS TRUST
- NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST
- NOTTINGHAM CITY HOSPITAL NHS TRUST
- Policy and regulation
- POOLE HOSPITAL NHS FOUNDATION TRUST
- PORTSMOUTH HOSPITALS NHS TRUST
- THE ROTHERHAM NHS FOUNDATION TRUST
- West Suffolk NHS Foundation Trust