Accident and emergency departments should be judged by two new targets alongside the four hour target, the president of the Royal College of Emergency Medicine has said.

  • Call for two new standards to look in more detail at time spent waiting and discharge ratios
  • £3m a week spent on emergency department locums, Clifford Mann says
  • A&E “hubs” could be set up to co-locate primary care with emergency services

Clifford Mann has called for a more detailed look at the time lost for a patient waiting and the daily discharge ratio in emergency departments, to be “sure and confident” that the two standards reflect what is happening in a department.

Dr Mann said: “One of the problems with the four hour target at the moment is it doesn’t matter if you miss it by two minutes or two days. Obviously it matters hugely to the patient… so what we’re saying is we should add up the minutes above four hours for every patient every day that there are breaches and then you have the lost patient time.”

He added: “The best way to drive down patient time is not to worry about somebody going to four hours, one minute as opposed to three hours, 59 minutes. It’s to get the 12 hours [patient] out in six hours or the 10 hours [patient] out in five hours.”

The second target would be a measure of the daily discharge ratio.

Dr Mann said this would be a comparison of the number of people a hospital discharged compared with those admitted.

Clifford Mann

Clifford Mann said improving the daily discharge ratio would increase flow through hospital departments

He added: “If you admitted more than you discharged you’re going to struggle to find beds for them.”

Dr Mann said this data is already collected by trusts and so there would be no extra burden on them.

HSJ asked Dr Mann if these two new targets should be performance managed in the same way the four hour target is used.

He said: “We would have all three standards so we would be sure and confident that all three were telling us the right information, but actually we would find that all three would be run in parallel.

“If you could improve your daily discharge ratio then you would increase flow through your departments, you’d be bound to reduce the lost patient hours and therefore you would achieve the four hour target.”

At a King’s Fund event yesterday, Dr Mann highlighted the cost of staffing A&Es with locums.

He said: “If you’ve got an average A&E department it costs £6.5m to run [a year]. Every week we spend £3m on A&E locums in England alone. So every fortnight we spend on locums what it costs to run an emergency department for a year.”

Dr Mann said it is “absolutely imperative” that whatever action is taken to reconfigure emergency care does not encourage more emergency medicine clinicians to leave the NHS to work abroad.

He added: “If we simply stopped people leaving we would already have a third greater workforce than we have at the moment. It’s absolutely imperative that whatever we do around how we reconfigure emergency care… we don’t discourage even more people from staying. We spend a lot of money training these people. Each of those people cost about £500,000 to train and they now pay tax to a different government.”

“There’s currently one emergency medicine consultant for every 11,500 A&E attendances and it doesn’t matter whether you work seven days a week or 12 days a week, that figure is inadequate,” he added.

Dr Mann called for “A&E hubs” to be set up that host out of hours primary care for urgent conditions, community pharmacy services, community mental health teams, links to palliative care teams and district nursing all on one site.

He said: “A&Es have become the default facility for ‘any and every’ out of hours care need, with the emergency medicine workforce treating patients who could best be seen by another service. Consequently, we believe that other services should be co-located with A&E so that patients attending A&E who could best be seen by another service can be redirected to the most appropriate service right away.”