• Average time A&E target encourages focus on less sick patients, say senior clinicians
  • Mean time in A&E target trialled as part of potential regime to replace four-hour target
  • Royal College of Emergency Medicine warns: “If nothing better can be found, then we see no reason to move away from the four-hour target.”

A new accident and emergency target which could be introduced early next year is “driving completely the wrong behaviours”, senior clinicians have told HSJ.

Several senior clinicians raised concerns about the average (mean) waiting time target to HSJ following the measure being extensively trialled, alongside several other measures, by 14 acute trusts in a pilot which began this summer.

System leaders, who laid out plans to trial new targets in March, were hopeful an average time target in A&E, and other measures, could underpin a new performance regime — replacing the four-hour standard that has been in place since 2004.

Performance against the four-hour target plunged to a record low last month. Every major acute trust in England missed the target in November, marking the first time this has happened. Overall performance fell to 81.4 per cent against the 95 per cent target.

‘The wrong behaviours’

However, a senior source familiar with the trial and high-level negotiations said the mean target incentivised the swift treatment of less ill patients. It also strips individual patients of the right to a specific maximum wait.

The source said: “One of the key reasons why the mean [average time target] didn’t work is you can’t apply it to an individual patient. Also, the only way to really drive down the mean is to focus on non-admitted, so that’s driving completely the wrong behaviours again.”

The source said the focus of the trial was shifting away from the building of a new regime around the average waiting time, and instead focusing on overcrowding and trolley waits.

The source added: “The current levels of crowding that are the root cause of corridor care are a real concern and so both [NHS England and Improvement] and [the Royal College of Emergency Medicine] are keen to develop a reliable measure of crowding.”

The Royal College of Emergency Medicine also backed the concerns raised.

An RCEM spokesman told HSJ: “[RCEM] has never supported an aggregated mean because it drives the same performance behaviour as the single four-hour standard does — fast management of less sick patients.

“However, the testing is looking at more than just that, so we are keen to see the data as they get more. As we have said throughout this process, if nothing better can be found, then we see no reason to move away from the four-hour target.”

HSJ approached NHSE prior to publication. NHSE did not comment on the allegation that the average time target was “driving completely the wrong behaviours” and encouraged focus on non-admitted patients.

It did, however, dismiss allegations made by senior sources to HSJ that overcrowding had risen in departments trialling the average time measure.

It said in a statement: “There is no clear difference between test sites and the control group when it comes to crowding as a result of using average time in department, whereas the test sites are successfully seeing a reduction in the conversion rate from A&E attendance to hospital admission.

“[NHSE medical director Stephen Powis] expects to be able to report on progress and make recommendations on urgent and emergency care standards in early 2020, as expected.”

‘Promising’

NHSE’s clinical review of standards review team’s progress report, published in November, said the trial of new metrics designed to “remove the four-hour cliff edge” had been “promising” but it was too early to draw conclusions and testing would continue over winter.

NHSE said in the November report that the results from the pilot study showed that, while overall waits had slightly lengthened by an average of six minutes, waits for admitted patients had been shortened and the total admissions had been cut (See box: Longer waits overall but less admissions, says NHSE pilot).

In addition to a mean time target, pilot sites were also examining “a rapid assessment measure for all patients arriving at A&E, coupled with measuring how quickly life-saving treatment — or critical time standards — is delivered”.

The report added: “NHSE/I has [also] been exploring the value of monitoring the average time in department for admitted and non-admitted patients separately, instead of having one aggregate mean covering both groups.

“This is because patients may be prepared to accept a slightly longer wait if they are able to go home, but it is still clinically appropriate for hospitals to do what they can to reduce the time that patients spend in A&E before being admitted.”

Unpublished data

Think tanks have consistently called on NHSE to publish the trial data so it can be rigorously examined by independent analysts. NHSE has to date only published selective parts of the data.

King’s Fund chief analyst Siva Anandaciva said, while the four-hour target had “its detractors and draw backs, it is certainly more straightforward operationally than an average wait”.

Mr Anandaciva added: “We would need to see the data from the trial sites to draw any formal conclusions and we would encourage NHSE to publish the data as part of any consultation exercise.

“But, certainly, there is merit in the argument that it would be unwise to get rid of the four-hour target unless it can be robustly demonstrated that alternative arrangements can deliver better outcomes for staff and patients.”

Longer waits overall but less admissions, says NHSE pilot

Overall waiting times for all patients at pilot site emergency departments under the new standards were six minutes longer than a baseline taken prior to field testing beginning.

But admitted waits fell by three minutes, from an average waiting time of five hours and 15 minutes, to five hours and 12 minutes.

Non-admitted patients’ average time in the ED rose by nine minutes from three hours and one minute, to three hours and 10 minutes.

While this meant seven out of 10 patients were waiting longer overall, NHSE said the study proved that “as intended, by spending slightly longer in A&E the proportion of patients who are admitted to hospital seems to have fallen”.

Nuffield Trust chief economist John Appleby said: “It really is too early to tell whether these new targets might be an improvement.

“From the initial analysis of A&E data, it remains unclear which people have won or lost out under this new regime.

“We really need to know this to decide whether longer waits for some are a price worth paying. Although new targets are likely to benefit some patients, so far many have been left to wait longer.

“Therefore it’s still uncertain whether these results truly deliver what this review was looking for — to ‘lock in short waits’. We are absolutely supportive of the idea of rigorously testing new targets but NHS England need to make it clear what success would look like.”

The baseline was taken six weeks prior to field testing. Field testing took place between 22 May and 1 October.