• Colleges intervene as NHSE bosses consider ditching the four hour target
  • Academy says it could be kept alongside any new measures
  • Leading option to replace four hour target is new ‘aggregated patient delay’ target
  • But the new metric’s inventor say it cannot replace the four hour target and doing so would be “bad for patients”

The four hour accident and emergency standard could be retained “in conjunction” with new targets for emergency departments, the leader of the medical royal colleges has told HSJ, as NHS England considers ditching the flagship measure.

The intervention of the leader of the Academy of Medical Royal Colleges, who is part of the group reviewing the targets, follows reports NHS England bosses are pushing for the four hour target to ditched.

The academy, which represents all the royal colleges, has not stated its position until now, with its member split over the future of the NHS’s most well known performance measure, which has been in place since 2004.

Several sources suggested to HSJ a leading option being considered as a replacement for the A&E target is a measure called “aggregated patient delay” (see explainer below).

HSJ understands other proposals being discussed include the average time spent in emergency departments and waiting targets covering the most seriously ill patients.

The APD metric records the total time spent in an emergency department by patients who have breached the four hour mark. 

In a statement issued to HSJ Academy of Medical Royal Colleges chair Carrie MacEwan said: “There’s no reason why the new measure [aggregated patient delay] can’t work in conjunction with the existing [four hour target] metric.”

She added: “What really matters is the quality of patient care… [The] current four hour measure is well known to be a blunt instrument, but it has been effective and any modification is likely to be more sophisticated to reflect the developments in emergency care and certainly something that has been fully tested, evaluated and shows that it delivers better results.”

The academy’s plea for a full evaluation comes with NHS England keen to drive through the changes this year.

NHSE has been pressing the case for reform of the target since the review of standards was announced last year, when NHS England chief Simon Stevens told HSJ it was outdated.

The Times, which reported today that NHSE wanted to scrap the four hour target, with the APD measure a leading option, also previously reported NHSE chair Lord David Prior’s call last month for the target to be ditched.

However, the inventor of the aggregated patient delay metric, Chris Moulton who is the joint A&E lead of the national Getting it Right First Time programme, told HSJ replacing the four hour target with the APD metric would not work and would be “bad for patients”.

Dr Moulton, vice president of the Royal College of Emergency Medicine, told HSJ: “Scrapping the four hour target and replacing it with the APD target doesn’t work.

“The APD measures total breaches past four hours, so if you don’t have the four hour target it doesn’t work.”

Asked if the four hour standard could be kept as a metric to underpin a new main target based on the APD, Dr Moulton said: “No. The idea of APD is that it is supplementary to the four hour target. It’s a flow and outcomes measure to help make the four hour target clearer.

“If you are not meeting the bar, you [work harder] to meet the bar. You don’t just get rid of the bar, which is what this would do.”

The new metric is already being recorded by all trusts and used by the GIRFT A&E stream alongside other measures including the admitted patient breach rate.

Explainer: what is the aggregated patient delay metric?

The APD metric measures the total time the average admitted patient which has breached the four hour target spends in the emergency department before being placed in a bed.

It was developed as a supplementary metric to the four hour standard to help address some of the perverse behaviours driven by the core A&E standard, help understand and improve patient flow and clinical outcomes, according to its inventor, A&E consultant Chris Moulton.

The APD only measures patients who have breached four hours, so the long standing waiting time benchmark represents the foundation on which the newer metric was developed, Dr Moulton said.

The metric was intended, among other things, to be used in part to address the “3:55 rush”, where departments sometimes focus on patients about to breach the four hour mark, potentially at the expense of other patients who have far longer than four hours.

There is no difference under the existing system on the headline target whether a patient breaches by one minute or ten hours – they are still marked down as breach. This has long troubled both clinicians and managers.

GIRFT data shows the average time spent by a patient admitted to A&E who has breached four hours was around eight hours, HSJ understands.

If a hospital recorded no breaches in its A&E, it would record an APD score of zero. The APD is expressed as the number of hours per 100 patients in order to calculate an average score and account for outliers.