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Published: 20/03/2003, Volume II3, No. 5847 Page 12 13

Trusts will have a period of just seven days to show that they have hit the crucial four-hour accident and emergency target. But why - and how? Paul Smith reports

This is a hell of a week in politics. But for managers and medics working in accident and emergency services, next week is - politically - the most important one of all.

End-of-year progress on the A&E target - that 90 per cent of A&E patients are dealt with inside four hours - will be judged against departments' performance over just seven days, starting on Monday. That is just 168 hours; 10,080 minutes, if you prefer. And every minute will count for a service which is under intense pressure to perform.

In recent weeks, the service has been filled with rumours about how the milestone would be measured. Finally, on Friday, managers were sent a circular telling them that the measurement period for the A&E target would be the last week of the financial year.

Prime minister Tony Blair has been directly involved in the push to ensure the very visible target is met. Last month, Professor Michael Barber, head of the Cabinet Office delivery unit, admitted that the 2004 final target - 100 per cent compliance - has been assigned 'level-3' status on a severity scale on which level-4 is the highest. A&E is the only health target to have been assigned this status.

This government has long been haunted - and taunted - by newspaper headlines and pictures of casualty victims 'warehoused' on trolleys and cramped into corridors.

Naturally, results against this year's milestone are the chance for a government under attack from all fronts to prove success on the battle on A&E. But has that pressure encouraged the NHS's political masters to define rules of engagement which will ease the path of apparent progress?

In short, what does a week really demonstrate? And will the temptation to throw unsustainable resources at those seven days and to cancel elective work in order to meet the A&E target services mean a slump in performance over April?

Whipps Cross University Hospital trust director of emergency care Dr David Cheesman says his hospital will not - and can't afford to - stoop so low.

But he admits: 'There is a danger that organisations would potentially cancel operations in the last week of March in order to meet the A&E target and That is not sustainable.

One week in 52 is a dangerous thing to do, because you could slip back after that. It would be tempting but we really need that last week [in order to meet elective targets].'

The trust has won extra investment to tackle A&E. That includes£2.5m for its emergency medicine centre - due to open in mid May - and£1.6m revenue funding. It has been spent in part on bringing in a dedicated A&E physician and the future face of A&E services, emergency nurse practitioners.

'We came from a dreadful position - 35 to 40 per cent [of patients dealt within four hours]. Then 64 per cent in January and last week 86 per cent.When we looked yesterday we had done 90 per cent for that day.'

But with the political temperature rising, British Association for Accident and Emergency Medicine president Dr John Heyworth is concerned that many trusts are taking a 'short-term, quick-fix approach'. For all the gut-busting going on this month, many feel improvements could prove unsustainable.

Dr Simon Eccles, an A&E registrar at Broomfields Hospital in Chelmsford, Essex, says his trust has one agency doctor and two agency nurses constantly stationed in A&E trying to help the department hit its target. Trusts are 'throwing money' at casualty departments because of the pressure put on trust chief executives to meet the targets, he claims.

'Resources are being taken from other parts of hospitals and diverted to A&E to make this work. If this continues, then other services will grind to a halt.'

He also says that without 'creative accountancy' many trusts in the London area would not meet the four-hour mark.

What is clear is that over the last three months a huge amount of managerial and staff energy has been expended. In the last quarter of 2002, only 78 per cent of patients (a total of 2.23 million) arriving in major A&E departments spent less than four hours from arrival to discharge, transfer or admittance.

If admission rates remain the same, trusts would need to have treated another 350,000 patients within the four-hour deadline to hit the target.

Money may have been thrown at the problem in some areas, but managers and clinicians say the solutions have been focused on funding redesigned services - not using one-off crisis cash.

Extra staff have been taken on at East Sussex Hospitals trust, for example - six emergency nurse practitioners at Hastings Hospital and vacant posts have been redescribed to bring in staff more suited to the new services.

There is also the recent introduction of 'see and treat' programme, run by the Modernisation Agency (see box, right) and social workers, ambulance staff and physiotherapists working within A&E.

In a month, treatment within four hours has gone from 73 per cent of those admitted to 85 per cent this week.

The improvements, according to acting hospital director Shirley Whiteway, are based on redesign.

The long list of changes has all been done, she says, within the 'financial envelope'. 'We are not simply doing more of the same to hit the target.'

But she also says: 'The reason we have done this has less to do with hitting the target for the DoH, it has been about our patients.'

Homerton University Hospital and Royal London Hospital A&E consultant Dr Stephen Miles says:

'SHAs have made a little extra money available. But bringing in extra staff over the short term has not really been an option because many trusts have the same idea.

The approach has been about redesigning services.

'We have been experimenting a little and It is going to be useful because we can turn round to purchasing authorities and demonstrate the improvements and commit them to invest.

'I think if you look at the trust in the north they have been performing at around 80 per cent for some time.

'The stress is going to be on trusts in London.My hospital has in the past been working at the low 60s. We may not hit 90 per cent, certainly the high 80s though and I do not consider that a disaster.'

On the question of the Department of Health decision to assess trusts for just the last week of March, he adds: 'I am not sure that a week is long enough to get an accurate picture [of performance]. But It is an index. The DoH will continue to look at waiting times. We have already received a letter from [health secretary] Alan Milburn wanting no-one waiting over four hours.

'Sustainability will be an issue in the short term, there may be a slight drop [in trusts' performance] but you have to look at what trusts have been doing. We have been working on the clinical pathway from front door to back door.

It is making the system more efficient but It is complex. The important thing about this kind of redesign is its permanence.'

Gloucestershire Hospital trust medical director Dr Guy Routh says: 'Everyone is concerned about the sustainability. This comes down to the growing demand on A&E services.

'But I really do not think It is reasonable to expect people to slack off. The target will not go away.'

It certainly will not.When targets are blamed for the woes of the NHS, when clinicians and managers want to be rid of most of those pouring from Richmond House, what becomes more curious is a widespread recognition that this year's A&E milestone has brought about change and has improved the holy grail of the service - patient experience.

Whether next year's target - when a 100 per cent of patients have to be dealt with inside four hours - is regarded with the same enthusiasm is another question.

There are concerns It is both unreasonable and clinically inadvisable.

Dr Miles at Homerton Hospital says: 'It is not in the best interest of patients, especially with patients needing resuscitation. I do not think It is a good idea to transfer them to a acute ward bed in the middle of trying to save their lives.' l This year's models: ways to cut waits The emergency services collaborative, co-ordinated by the Modernisation Agency, is specifically designed to help the NHS meet the four-hour wait target for accident and emergency departments.

Starting in October 2002, the programme - which covers four broad areas of A&E management - is being rolled out in six waves, each made up of around 35 sites.According to the agency it should cover all sites in England by 2004.

In practice, this has meant opening up access to diagnostic services and creating dedicated assessment services and an emphasis on bed management.But it is the 'see and treat'concept that is being increasingly talked about by A&E managers.Of all the Modernisation Agency initiatives, it seems to be the one about which the organisation feels most pride.

It was first used by A&E consultant Dr Angela Dancocks at Kettering Hospital in October 2001, replacing the triage system which centred on tackling the most serious cases first, with patients with minor injuries left until over-stretched clinical staff were free to deal with them.

At Kettering, see and treat meant that patients were seen as soon as they arrived by either a senior doctor or nurse.They were treated immediately unless more in-depth assessment was required. Implementation was not easy - staff often felt that 'minor things can wait'.Nor was it seen as an exciting side of A&E work.But the results were impressive.Originally,52 per cent of minor injury and illness patients were being seen within one hour.Within a year it was 77 per cent.

The approach was adapted at Hillingdon Hospital in November 2001.Called Access, Treat and Complete, it involved minor cases registering at reception before they were sent to the ATC area where they were treated and discharged by either a doctor or an emergency nurse practitioner.

Patient journey time fell from three hours fifty minutes at the beginning of the programme to just 50 minutes 10 months later.

Today, see and treat approaches are operating at 58 per cent of A&E departments.As Whipps Cross University Hospital trust director of emergency care Dr David Cheesman says: 'If you can sort your minors out, admissions only count for 20 per cent of your work. In theory if your minors are being done within the four hours you can get up to the 80 per cent instantly.The rest depends on how your bed state is.'

But the Modernisation Agency's Karen Castille, director of emergency services at the collaborative, believes the importance attached to the A&E target has not been a main driver in trusts introducing see and treat.

'They have wanted to do this because It is better for the patients and better for staff in the way they work.That is the reason.'