Exclusive: Fresh A&E data fiddle concerns revealed

The issues uncovered represent the latest data controversy surrounding the politically-sensitive four-hour target following a UK Statistics Authority probe into concerns around how trusts were reporting against the standard in winter 2017-18.

By September, every hospital must have a same day emergency care unit, designed to treat patients judged to require several hours’ worth of treatment, tests or observation and avoid the need to admit them to an overnight bed, under new rules.

There is significant clinical support for the units – which represent a key plank of the NHS long-term plan’s urgent and emergency care policy – and system leaders have vowed they will help improve care, patient experience and flow. The plan, published in January, set a target to increase the proportion of acute admissions discharged on the day from a fifth to a third.

With between 20 and 30 per cent of emergency admissions being triaged into SDEC units, it means any tampering with this data could have a huge impact on a trust’s overall performance figures – and multiple NHS sources, at local and national level, have raised serious concerns to HSJ about the issue.

One senior NHS figure said the project was used by some trusts to “just get the ED figures better” without necessarily changing clinical practice.

Rebranding 

Local clinical staff supported the claim, alleging some trusts were wilfully misusing the new units as vehicles for taking a significant chunk of accident and emergency admissions off the four-hour clock to avoid breaches – but without changing the care they receive.

A senior staff member at a large A&E department told HSJ: “SDEC as a concept is sound. But what is happening in reality is [some] trusts are just rebranding part of their emergency department as an SDEC unit and saying: ‘These patients no longer count in the four-hour data’.

“But there’s no actual change in clinical practice – it’s just an exercise designed to game the system. The patients in the SDEC just end up waiting longer, but are no longer on the four-hour clock.”

A national figure warned the fresh attempts to game A&E data were “not acceptable and needed to be called out [otherwise] there’s a real risk they will discredit the whole SDEC project”.

It is not clear how many hospitals have attempted to manipulate their data this way but HSJ has been given the names of several trusts where staff have concerns.

Among them were two University Hospital Southampton Foundation Trust staff members who independently raised concerns to HSJ.

The trust’s A&E staff were told to move patients to the SDEC unit, which took them off the four-hour clock, despite official trust guidance, seen by HSJ, stating that “in the short term this doesn’t alter the way doctors and nurses look after patients”.

One member of the trust’s ED staff told HSJ: “This change has caused huge anxiety amongst senior nurses and doctors in the department. We have huge concerns this is simply gaming the system.

“We have rebadged an area in A&E and made it a clock stopping area. There is no change in the environment or standard of care. Simply changing the name.

“Nothing will change about who sees these patients or where, they just won’t be counted as breaches. Our worry is patients will be made to wait over those that are counted.”

The trust, however, told HSJ the matter had been “addressed”. Chief operating officer Caroline Marshall said in a statement: “The concerns outlined by staff to HSJ [were raised to the trust leaders and] have already been addressed.

“Some patients require more than four hours to complete their assessment and treatment, but do not require a hospital admission and we are trying to identify that group of patients.

“This involves trialling measures to improve the flow of patients through the emergency department, including expanding the use of same day emergency care practices where it is appropriate to do so.”

Asked to clarify how the concerns had been addressed, a trust spokesman told HSJ the trust’s management was still working with department staff to finalise arrangements. The overall aim was that “all patients in our ED receive the right clinical care in a timely manner” and the trust’s SDEC pilot “has been modified to address the issues raised,” the spokesman said.

“I can’t say I blame them”

Society of Acute Medicine president Nick Scriven, who has worked with NHS England to develop the SDEC guidelines, said he was aware of the risk of gaming but he had not been aware of any trusts actually doing it.

Dr Scriven told HSJ: “The move towards SDEC is one we very much support [but] like any measure, there is a risk that SDEC units could be introduced by trusts in a way which means little change in clinical practice but ensures these patients don’t get registered as four-hour breaches, simply by moving them to a different part of the ED and taking them off the clock”.

The SDEC policy is, however, not without its critics. A well-regarded NHS clinician raised concerns about the way the policy was being rolled out.

The source told HSJ: “I have heard of hospitals which are doing this, but I can’t say I blame them. Trusts are overstretched and understaffed so no-one should be surprised when they do the bare minimum on a programme which has been mandated to improve four-hour performance.

“It reminds me of a rerun of the first acute medical units. A lot of places did it properly, but some just stuck a label on a convenient area and started shoving patients in them. It’s an inevitable by-product of overcentralised management practices coupled with a lack of resources.”

NHS national clinical advisor on A&E Cliff Mann said: “Trusts have been making great progress towards delivering the long-term plan ambition for every major hospital to have an SDEC unit by the end of this year, with broad clinical consensus that this model of care provides improved outcomes and convenience for patients while making best use of NHS resources.

“While it is important to address any local concerns there is no evidence of a wider problem, with the new emergency care data set allowing accurate and transparent reporting of SDEC activity and outcomes, supporting regional and national oversight to ensure that it is used appropriately.”