Debate on changing the standards to date has focused on the higher profile accident and emergency four-hour and elective surgery 18-week standards. While there are common features involved in changing any individual standard, the reality is that each proposed change needs to be examined on its own merits and will have its own set of relevant factors. It is important that the debate does not default to a generic ’lowest common denominator’ conversation about change in general or use proposals to amend the four-hour A&E standard as a proxy for the package of proposals within the clinical review of access standards as a whole.
We set out detailed feedback which we have received on each of the proposed new standards below from clinical and operational perspectives. Each standard under review has its own specific clinical and operational issues. However, there are some overarching considerations around the implementation of any changes which run across each clinical area:
- workforce challenges
- digital and technical capacity and capability
- information and data governance
- infrastructure and facilities constraints
- whether full opportunity has been taken to embrace the move to system working, or whether the proposed new measures are too organisationally focused.
Mental health proposals
Providers support the move to extend the breadth of the mental health standards. This is an important step towards parity of esteem in providing more information and data about the demand for mental health services. Hopefully, it will also help shift the current perverse incentives linked to the current mental health investment standard which does not always enable funding for mental health to reach the frontline as intended. Understandably, progress in this area is slower and it is important that all partners are brought into examine the proposals and comprehensively test new standards.
However, it has been noted that there are a number of barriers that may inhibit progress and successful implementation. There is a need to invest in building up mental health community provision and providers would welcome greater alignment between the review of clinical standards and NHS England and NHS Improvement's helpful programme to look at the model of provision for community services more generally.
Both acute trusts and mental health trusts flagged concern the introduction of psychological assessment centres in emergency departments may drive patients to acute hospitals and not community services, placing even more pressure on this pathway.
It is also clear that many mental health trusts do not necessarily have the digital capability required to implement the breadth of the proposals. Due to the nature of the referral-based approach, and timescales in the proposed standards, there is work to do locally between primary and secondary care providers around information sharing and data governance to build the capability. In the long run, this may be a positive development and further support local collaboration. However, building IT capacity across the sector will take time and have resource implications for trusts.
Urgent and emergency care
The proposals set out in the review mark a move away from one single measure – the four-hour A&E waiting time target – to a wider basket of urgent and emergency care measures. These include time to initial clinical assessment, time to treat the most critically ill and measuring the average wait in A&E.
Updates from the pilots show positive developments in consistently reducing the number of emergency admissions and the longest waits. It is also clear from research by Healthwatch shows that waiting time alone does not dictate how people feel about their experience of A&E and that the public may relate to a mean wait. However, it is still unclear if trusts and the public will be issued with guidance on 'what a good average wait' looks like.
The current A&E target acts as an operational tool to assist trust with moving patients through the hospital and into other services. Feedback from our members suggests that this is harder under the new standards as operationally you cannot ascribe a mean wait to an individual patient – which prevents frontline staff from having a clear operational lever at their disposal to maximise patient flow.
There are also data and IT challenges. To fully move to the new basket of measures trusts need to submit data to the emergency care data set (ECDS) and a number of condition specific data sets (relating to the standard for those who are critical ill such as stroke, heart attacks etc.). The ECDS has been in development for a number of years and the ambition is that trusts should be in a position to submit data in a timely and accurate way
However, providers tell us there is huge variation in trusts' ability to submit the full range of data required by the new standards. Digital capability is an issue for a significant proportion of acute trusts, and in the case of the new standards, is largely linked to the implementation of electronic patient records systems (EPRs). Without significant financial investment and support from national bodies, it is unclear how trusts who do not currently have the EPRs or the IT systems they need, will be able implement (and be held account) for delivering the new standards.
In addition, the proposed standards introduce new time points at which trusts need to capture data e.g. time to assessment. There must be clear and concise definitions around new measures to ensure trusts are consistently measuring the same things.
Trusts have told us that the additional clinical and operation data requirements are extensive and time consuming. Therefore, the value in dedicating additional clinical, coding and administrative time to implementing changes needs to be clearly understood and communicated to frontline staff.
Some trusts have queried whether the new basket of measures are too organisationally focused and whether they will act as a 'barometer' of system capacity in the same way as the four-hour target.
Trust leaders say that as with other areas of care, recovering the level of performance inherent in the current A&E standard is simply unachievable without an expansion in capacity and the right sizing of emergency departments, as well as expanding community and mental health support. Trusts welcome the recognition of this in the 2020/21 planning guidance, but we need more information about how improvements in performance will be operationalised and funded.
The proposed standards include the current six-week diagnosis standard, a move to an average wait target or fixed-week target and the supporting measures, 26-week patient choice offer, and the elimination of people waiting longer than a year. These two supporting measures set out in the 2020/21 planning guidance.
As a result of the longer periods of time involved in the elective care pathway, testing will continue into 2020/21 and therefore we will need to wait longer before we have any early indications of the benefits or possible drawbacks.
We know that elective care is currently a key concern for providers who are doing all they can to manage longer waiting lists than ever before. Trusts allocate beds and staff to help reduce the waiting list but with extreme pressure on emergency and cancer care, capacity is often the most challenging factor. We have consistently called for a growth in the number of beds in acute hospitals to help relieve these pressures. Trusts tell us that changing the standards in elective care must be supplemented by an expansion in capacity.
Capacity constraints are also being compounded by workforce challenges. In this area of clinical practice, shortages in the consultant workforce are being exacerbated by the ongoing NHS pension and tax issues.
Trusts are positive about the ambition behind the new cancer standards and agree the new proposals will act in the interest of patients by driving faster diagnosis and treatment. In some respects, cancer services are better placed to move to the new standards as they already measure distinct points on the patient pathway. On the whole, this means trusts have the appropriate IT capability and implementing the changes will require less support.
However, trusts have expressed serious concerns around the deliverability of the new standards given specific workforce challenges in diagnostics and oncology, the need to update and invest in scanners and equipment across the country and the required roll out of rapid cancer diagnostic centres. Trusts have also told us that they are struggling to resource the necessary administrative support to implement the faster diagnosis 28-day standard despite welcoming it as a positive move for patient care.