NHSE told to set new A&E ‘maximum time to assessment’ target

Healthwatch England has interviewed patients, carried out surveys and analysed feedback, to formally advise the controversial NHSE clinical review of standards.

One of the measures being tested in NHSE’s pilot sites for emergency department measures is the “time to initial clinical assessment”. There has been open discussion of measuring average waiting times in departments, but not so far of setting any new target maximum waits — as is the case with the current four-hour cut off for admission, transfer or discharge. 

In its report, shared with HSJ and due to be published today, Healthwatch said: “While the proposal of a new performance measure focused on the time to initial clinical assessment is in line with patients telling us desire for a quick first assessment, just tracking the time to initial clinical assessment is not enough to ensure urgent cases are not missed.

“We would like to see a maximum time-to-assessment target put in place for all those attending A&E, alongside a commitment that first assessment will be clinically and emotionally meaningful for patients.”

The national health watchdog also said NHSE should:

• Continue reporting against the current four-hour target, at least for a transition “period”, to help compare performance over time. It said some are sceptical about the timing of the review — with performance against the four-hour target having been in decline for several years. It said many want to know, “what success would look like under any new targets and how this would be explained without being able to compare it in some way with the current target”.
• “Set out a longer period for implementing any alternative targets” and suggested “staggering the roll-out to help build trust in the new methods of performance reporting”, while keeping new measures and targets “under continuous review”.

The report, based on interviews with 330 patients in six of the EDs trialling the new measures, also restated Healthwatch’s previous observation that long waits are not the overriding factor which matters to patients.

There is, it said, a “growing body of evidence that suggests what shapes experiences of A&E is not just how long people wait, but the quality of care they receive and how it’s delivered”.

“The overwhelming message is that time alone does not dictate how people feel about their experience of A&E,” the report said.

“Focusing performance measures on simply tracking time spent in department, however it is measured, will not necessarily drive the improvements the NHS wants to see.”

Patient experience in A&E is also driven by factors such as the quality of care, communication, attitude of staff, how joined up the department is to services such as NHS 111 and GPs and the quality of the facilities themselves, Healthwatch found.

Healthwatch interviewed patients at Cambridge University Hospitals Foundation Trust, Portsmouth Hospitals Trust, Imperial College Healthcare Trust, West Suffolk FT, Poole Hospital FT, and Mid Yorkshire Hospitals Trust.

Proposals to change the four-hour A&E target have been highly controversial, with some doubting the wisdom of and motivation for doing so. The Royal College of Emergency Medicine has changed its position over recent months, but in January its president said there was “nothing [from NHS England’s review] to indicate that a viable replacement for the four-hour target exists [and] we need to get back to the business of delivering on it”.

The health and social care secretary Matt Hancock and NHSE chief Sir Simon Stevens, meanwhile, have separately indicated for some time that they favour change to the target. 

NHSE has indicated changes will be phased in from April, but they will need to be approved internally and by government. Government has also previously said it would publicly consult on them.

NHS Providers, which represents trusts, has not come down either for or against dropping the four-hour target. Its director of policy and strategy Miriam Deakin said in response to the Healthwatch findings that it welcomes the “recommendation that any new A&E targets are phased in to ensure trusts have the right support, infrastructure and resources in place… And that the current standard should be phased out over time to allow for full transparency around the level of care the public are receiving”.

She added: “It is worth remembering that access standards fulfil a number of functions in the NHS. This includes providing accountability to the public and acting as a proxy for quality, supporting operational management and acting as measures of regulation. In our view any proposed changes to the standards must also take these multiple roles into account.”