• Claims 50 per cent of A&E admissions could be treated elsewhere dismissed as “utter myth”
  • Controversial option to scrap four hour target for minor ailments explored as targets review prepares preliminary report
  • Senior managers split but heavyweight backers voice support

Potential plans to ditch the four hour target for minor ailments are based on the “utter myth” that a large number of patients should be seen elsewhere, a senior emergency chief has told HSJ.

Royal College of Emergency Medicine president Taj Hassan made the comments as it emerged the option was being “explored” by the NHS targets review, alongside other potential changes, such as shorter targets for the most critical admissions.

Senior sources confirmed the proposals had formed part of discussions. But they added it was not clear if options would be explicitly spelt out in the first phase of the targets review expected in or alongside the delayed NHS long-term plan.

They said the first report by the review, launched by prime minister Theresa May in June, was more likely to set out a direction of travel rather than firm recommendations.

But the RCEM was swift to outline its opposition to the proposal and raise fundamental questions about NHS England’s belief that 50 per cent of accident and emergency attendees could be seen elsewhere.

NHS England deputy chief executive Matthew Swindells has consistently stated “about 50 per cent of patients could be treated elsewhere, could have gone to the pharmacist, or primary care… We need to shift the patients, we need to get them to a more appropriate location”.

But Dr Hassan said: “It’s an utter myth to suggest that 50 per cent of emergency department attendees should be seen somewhere else. In my hospital around 12 to 13 per cent are streamed to the GP.”

He said, in areas where access to primary care was poor, 20 per cent of A&E attendances could have been seen by GPs.

He added: “I can see why policymakers could want to scrap the four hour target for minor illnesses, but it’s not really that simple, and they have to understand the potential unintended consequences.

“It could lead to patients whose symptoms were deemed not to be serious on first assessment but actually did have a serious condition waiting far longer than they should do.

“It could also mean less resources for emergency departments which would then lead to further overcrowding. Longer waits as we know also lead to staff at risk of facing increasing verbal and physical abuse.”

System leaders view the review as a golden opportunity to update the target to bring it in line with the substantial changes in clinical pathways over the period. NHS England chief Simon Stevens has previously told HSJ the target was outdated.

But attempts to reform the A&E target, which has been in place since 2004, have been swiftly shot down. Critics have accused policy makers of plotting to rid themselves of an unmet target – the 95 per cent standard has not been met since July 2015 – and opening the door to lower service standards rather than trying to improve care.

In January 2017, then health secretary Jeremy Hunt floated scrapping the target for minor attendances, suggesting that around 30 per cent of A&E attendances could be dealt with by GPs or in other settings.

His intervention followed NHS Improvement’s efforts in 2016 to develop a new A&E “scorecard” to address the perceived bluntness of the four hour standard. Both were ditched, the first due to political backlash and the second also encumbered by the complexity of the task.

Similar opposition is already mounting against the fresh attempt. A source familiar with the current review’s discussions told The Guardian, which first reported the proposal was back on the agenda, the review was trying to “move the goalposts”.

Ministers have always stressed the review, run by NHS England medical director Steve Powis, will be clinically led. But other clinical groups, like the Royal College of Surgeons, share the RCEM’s position that the target is a vital quality backstop.

Other senior figures also raised concerns to HSJ that removing a chunk of minor injuries from A&Es would simply shunt the pressure onto other parts of the primary and community care system, which may be even less well-resourced than the emergency department, if they exist at all.

Some well regarded managers, however, said the move could be done in a way which could improve patient care.

Jim Mackey, who was NHSI chief when the A&E scorecard was under development, told HSJ he would support consulting on “an updating of the standard”. But he stressed a full and proper consultation and engagement of staff and the public, and evidence that reforms would deliver improvement rather than eroding standards would be needed.

The Northumbria Healthcare Foundation Trust chief said: “We see large volumes of people [in A&Es] who could have their needs met in a different setting… When systems and EDs are under pressure, this adds considerable risk from a crowding perspective.”

He cited an additional target to drive “more rapid attention than we currently offer for the frail patient group” as an example of “an opportunity to improve standards of care” by reforming the four hour standard.

But he also warned such a move would require the relevant GP, primary and community services to be in place so patients could “access the appropriate service in a timely fashion”.