The clinically led review of NHS access standards in England: The Royal College of Emergency Medicine’s view

In 2018, the Medical Director of NHS England announced a review of all the access standards, not just urgent and emergency care. The motivations for this are probably mixed, but the four-hour standard has not been met in English hospitals since 2015 and only sporadically in a few hospitals and there is a recognition that the standard had ceased to work to drive improvement. A pilot of 14 hospitals was conducted to trial different metrics. In December, NHS England published a public consultation document. This is a necessary step before a change to access standards, which are enshrined in the NHS constitution, can be made. These standards are reportable, which means that they will end up in the public domain.

Emergency departments are in great difficulty and there is a compelling reason to try and make things better.

   

RCEM has been in the discussion right from the beginning and our voice is clearly heard in the consultation document, though these are not our standards. It is welcome that there is explicit recognition that crowding in emergency departments is harmful and should be urgently addressed. Emergency departments are in great difficulty and there is a compelling reason to try and make things better. More than 60% of departments score 'needs improvement' or 'inadequate' for patient safety in Care Quality Commission reports and NHS Resolution shows litigation second only to orthopedics in volume and maternity for value. We need renewed energy to get our departments working for our patients.

So, what are the new standards and what do they mean for us?

The four-hour access standard as the sole measure of performance in emergency departments is removed. This is replaced by a number of measures in different parts of the pathway, pre-hospital, emergency department, hospital and whole system. Some of these, especially ambulance handovers will be familiar.

There is explicit recognition that a problem in one part can be caused by problems elsewhere. Delayed ambulance handovers are part of the emergency department measures, while long mean times for admitted patients are recognized as hospital problem. These new standards would also shift focus from an individual clinician feeling responsible for the time that their patient spent in an emergency department, towards a service level responsibility for the overall time. The splitting, or disaggregation, into admitted and discharged patients should illustrate the problems of exit block more usefully.

The move to a 12-hour length of stay, rather than the misleading 12-hour decision to admit (DTA) metric is welcome and long overdue. This is a simpler and more patient centred measure, RCEM will continue to argue that no one needs to spend 12 hours in an emergency department. Having DTA plus 12 hours has hidden a huge problem that has contributed to patient harm and very low morale in emergency care staff. The longest stay are so often experienced by the most vulnerable patients. Often the gap between externally reported 12 hour breaches and the actual number of patients with very long stays in departments is very large. The official 12 hour DTA breeches for 2019/20 was 8,272 while the number of patients in departments more than 12 hours was over 500,000.

RCEM believes it in everyone's interest to have transparent data so that we focus on the right things to improve. It is also very important that 12 hours does not become the new four hours. That is explicitly not the intention, there is evidence of patient harm after six hours and RCEM would hope that the threshold around mean LOS for admitted patients keep organisations very aware of flow. There are undoubted difficulties in defining time to initial assessment, and we would not want to return to the 'hello nurse' just to tick a performance box. The 'ready to proceed' measure is intended to replace the 'decision to admit' metric. The intention of this measure is that this must be owned by the emergency department staff, and not by inpatient teams and this should further illuminate exit block. This will require a careful definition to avoid the problems of gaming. The clinical standards measure across the system, so include patients who bypass emergency departments and go directly to PCI or stroke centres. These patient groups are likely to be a small proportion of the emergency departments census.

The findings from the pilots are of limited value, other than demonstrating that this did not lead to catastrophe. There was some indication that the spike in admissions that we see between in the last 15 minutes of a four hour stay lessened and there was a reduction in short stay admissions. It is, however, clear from the pilots that removing reporting oversight and operational grip lets crowding worsen, a condition of participating in the pilot is that Trust Boards were excused operational reporting.

There are areas of concern within the consultation paper. The thresholds are not defined, nor how they would be worked out, or used to compare different emergency departments. It is likely that establishing the time thresholds will require an assessment of the likely costs.

While a single number, the four-hour standard makes comparisons between departments easy, it probably oversimplifies a complex system.

   

RCEM is clear that these measures need to be reported fully, so that good performance in one area does not hide poor performance in another area. We have all seen adoption of minor injury units and urgent treatment centres to improve four-hour access performance. While a single number, the four-hour standard makes comparisons between departments easy, it probably oversimplifies a complex system. The value of multiple measures describing a system carries both benefits and risks. On the one hand, multiple measures reduces gaming and perverse incentives, conversely focus and effort may be diluted. For many years, we have successfully argued that crowding is mainly caused by exit block and inadequate bed capacity and we should support a performance framework that illustrates this more explicitly.

Many emergency physicians will be anxious about not having a four-hour standard, indeed there are younger emergency physicians who have spent their entire career working with the standard. We can both remember the vocal opposition to the introduction of the four hour standard. We also remember that some places had to initially record the times manually and transcribe from paper into spreadsheets. Most of us are working with more sophisticated IT systems and we can surely capture more meaningful measures of flow. The nature of our work and the scope of our practice has changed significantly over the last 10 years. Our patients are older, more complex, less injured and more sick and our access to rapid diagnostic tools has transformed the way we work.

There are also legitimate concerns about implementing a major change management program in the middle of the pandemic. However, realistically for the last five years, the standard has not become an effective measure to improve flow and has become a toothless tiger. Furthermore, as hospital capacity has declined, there has been greater need to identify and quantify exit block. Retaining the four-hour standard within these measures risks repeating the same problem we had with the key performance indicators in 2011, where a sensible suite of indicators was subsumed and eventually ignored by sole focus on the four-hour standard.

Measurement alone, as any quality improvement expert will tell you, does not improve care on it's own. Some items, related to time, can be implemented and reported very quickly. Other items with more complex definitions, will require more development and investment. We argue that a phased approach to implementation would be more likely to be successful. Changing metrics without operational commitment would be unacceptable. The pandemic has shown how essential emergency care is and that that system is fragile. If we want some positive outcome from the pain of the last year there must be change, collaboration and a vision of a better service. The clinical review of standards process has given us the chance to reflect on what the future could look like, and however the consultation concludes, that has been immensely valuable.

Failing to enter next winter without a better set of tools to improve care would be a disservice to our patients and staff.