The first output from the long-awaited review of clinical standards has now been published.
One of the most contentious areas is urgent and emergency care – with a proposal that the target for 95% of patients to pass through A&E within four hours should be replaced by four new measures. Exact details of how these measures might be turned into targets is not yet clear. But importantly, the review suggests moving away from setting a maximum time that any individual patient should spend in A&E. Instead, performance will be measured against the average or mean time spent across all patients in each A&E department.
This is a big shift in one of the NHS’s most totemic targets, and it raises some important questions. Will the new measure make sense to patients? How will it affect the performance of individual A&E departments? And what impact could it have on how long patients spend in A&E?
What does the “mean” mean?
In 2017/18, the mean time patients spent across all types of A&E departments from arrival to either discharge, transfer or admission was two hours and 53 minutes.
But this masks significant differences for individual patients, with a long tail of people spending significantly longer in A&E than the four-hour target. In 2017/18, one in 100 people spent over 14 hours.
As the next chart shows, there is a steep climb in the proportion of patients leaving A&E until the four-hour mark is reached. At this point, the rate at which people leave slows down, perhaps because the incentive to deal with them quickly to meet the target no longer bites. Although only 5% of people should wait more than four hours, in 2017/18 14% waited over this time. It was well over seven hours before 95% of patients left A&E.
There are also big differences between A&Es, and between groups of patients. The mean time is longer for major A&E departments, at three hours and 24 minutes, and for patients who end up being admitted, at four hours and 55 minutes. This makes sense: patients who are admitted are more likely to have tests and investigations in A&E and may also have to wait for a bed to be available.
The chart below shows the scale of the differences that exist between NHS trusts, both for all patients and specifically for admitted patients. In 2017/18, one trust reported an average time in A&E of nearly nine hours for admitted patients.
Will there be winners and losers at organisational level?
A question that will preoccupy many trust leaders and local patients is whether hospitals that do well or poorly on the old measure will look the same on the new one. We don’t know exactly where a new target will be set, but we can see that performance on the current and proposed standards are correlated overall (see next chart).
But the relationship is far from exact. Among trusts with longer than the average time spent in A&E in 2017/18, the percentage of four-hour breaches ranged from 6.6 to 35.3, and among those with shorter than average waits, the range was from 2.3 to 33.8. Trusts would do well to investigate their current average time – and their data quality. Even those currently closer to the four-hour target won’t necessarily have a shorter average time.
Are the measures clear and straightforward for patients?
For patients, what probably matters most is how long they expect to have to wait, and how long they actually have to wait.
The mean masks important variation in the time individual patients are likely to spend in A&E, and on its own could make it tricky for patients to know what to expect in the future. Of course, a similar criticism could be made of the existing target – and this is why it is probably a good thing that NHS England plan to have other standards alongside the new one.
But one important difference is that the new standard applies to hospital trusts, not individuals. Under the current standard, patients can see the pledge that they should be assessed and treated, transferred or admitted within four hours as a commitment that nearly everyone should receive. When the standard moves to an average, around two-fifths of patients are likely to be spending longer in A&E than the average.
There might be a risk of disillusion in moving from a target where the expectation is supposed to be met almost all the time, to one in which it is only met much of the time – even if the new standard were to be overall more ambitious.
Will we know if the standards are an improvement on what we have now?
A critical matter for patients is whether the new standards will really drive improvements in the quality of care.
Under the new measure, if patients spend a long time in A&E, this will have a much greater impact on average reported performance. Ten patients spending ten hours each will count the same as 100 patients spending one hour. If hospitals respond to the target by addressing only very long waits, this would bring the average down and benefit some people greatly. But there would be little noticeable impact for the majority of patients.
Currently, at a national level the mean waiting time today is skewed by those hospitals where patients spend very long times in A&E. This is particularly the case for major A&E departments, where only 37 providers (27%) have longer mean times than the average for these departments.
A fall in the longest waits could result in relatively rapid improvement in average time spent in A&E. But as performance evens out, this apparent improvement will be increasingly difficult to sustain.
A key challenge for the government and NHS leaders will be whether the new standards are seen as a watering down of care.
It will therefore be critical to set the standard for acceptable performance at the right level. Given that the average time for admitted patients is already well above the four-hour standard, there does seem a real risk that the proposed standard could lead to an impression of improvement without much actual benefit to patients.
Scobie S (2019) "What will the proposed A&E waiting time targets mean for patients?" Nuffield Trust comment.