- New one-hour sepsis target could encourage A&Es to move patients on too quickly
- Sick patients could be left longer as staff focus on cases with one-hour target
- Concerns raised targets review is attempt to divert attention away from performance and has a “pre-determined answer”
A new one-hour target for sepsis, set out in NHS England’s standards review this month, could encourage “bad clinical practice to beat the clock”, a senior clinical leader has cautioned.
The warning comes amid concerns from senior NHS managers that the new targets proposals are, at least in part, an effort to divert attention away from the NHS’ poor performance and are being forced through by NHSE without proper consultation.
The Society of Acute Medicine’s president warned sepsis patients, among others, could be shunted out of the emergency department and into less well-resourced acute medical units while other very sick patients are forced to wait longer than clinically optimal under the proposals.
Nick Scriven told HSJ: “We have not seen the detail yet, but a one-hour target for sepsis could lead to bad practice to beat the clock.
“The emergency department won’t always have time to do the job properly, so they’ll be incentivised to give the patient a shot of antibiotics and move the problem onto the acute medical units.
“The ED will hit its target, but the problem will just be moved onto the AMUs, which are less well staffed than EDs. So, the clinical benefits are not clear.
“There is also a concern very sick patients who don’t have sepsis, or fit into other categories which will have a one-hour target, will be forced to wait longer.”
The UK Sepsis Trust said it welcomed the new standards which “represent an important step towards driving improvements in care”. But the trust also recognised the risks raised by Dr Scriven and warned safeguards would need to be in place.
Dr Scriven’s intervention follows the publication of NHSE’s Clinically-led review of NHS access standards: Interim report from the NHS national medical director.
The controversial review, led by NHSE medical director Stephen Powis, sets out plans which could see the four-hour target scrapped. The proposals also set out plans for shorter one-hour targets for critically ill and injured patients, including heart attack, major trauma, sepsis, severe asthma and mental health presentations.
The review’s publication was accompanied by supportive statements from royal colleges including the Royal College of Surgeons and Royal College of Physicians, who were involved in drawing up the plans.
But there are concerns from other groups, such as SAM and the Royal College of Emergency Medicine.
Senior NHS managers have, largely privately so far, also outlined a series of other problems to HSJ about the review, with many feeling both managers and key clinician groups are being kept out of the process.
The concerns raised include:
- Chief executives telling HSJ they feel the targets review is a fait accompli with a “process following a decision”;
- Accusations of system leaders using the review to try and divert attention away from poor performance rather than to develop clinically optimal standards; and
- Warnings many trusts do not have the technology to measure the new one-hour targets in place and procuring the means of doing so would require funding and time.
One senior provider sector executive said: “There is a sense that, yes, we need to look at clinical standards, but that there is probably a pre-determined answer [already decided by NHSE].
“It’s probably 60 per cent about taking the focus away from performance, and 40 per cent that we need a good look at these clinical standards because they have been in place for a long time and we need to make sure they are right.
One trust chief executive said: “I think we’re getting rid of [the four-hour target] because it can’t be met any more.
“We may well be seeing the start of a direction of travel where NHSE make decisions about clinical standards without proper consultation with the professional bodies and the clinicians on the ground who actually know how services are delivered.”
Another acute provider chief said: “My trust can’t meet the standard anymore, mainly [because of] workforce issues. That doesn’t mean abandon the standard – it means, let’s focus on workforce.”
NHS Providers called for a “robust process of engagement to go with the suggested new targets and to test them”.
Deputy chief executive Saffron Cordery added: “A number of revised targets have been suggested for piloting. So we also need to have the courage to say, ‘We’ve tested this, and it’s alright – we’re not going to implement all of them but we will prioritise those which serve patients best.’ It’s vital we get the process right.”
She also warned: “We have used the A&E target to educate the public and politicians about what good looks like in the system. If we are going to move away from that it needs to be a lot more than an NHS-focused process of… testing and then implementing [new standards] with full consultation.”
The UK Sepsis Trust said: “[The standards] represent an important step towards driving improvements in care. However, we need to ensure these regulations are designed robustly in order to mitigate against unintended consequence, particularly with regards to judicious use of antimicrobials.
“Though it is a shame that such standards have to be set to drive improvements in life-saving care delivery, the reality is that they are an effective method of ensuring rapid care is given to those who need it most, and will most likely continue to be introduced.”
An NHSE spokesman said: “The clinical recommendations in the NHS national medical director’s interim report have received widespread support from the major clinical and patient groups, and are now going to be carefully field tested with local hospitals.
“The data showing unintended consequences of some of the legacy targets are now clear, so it is right to carefully consider - over what will have been more than an 18 month period - whether there are better alternatives.”
Interview and information provided to HSJ