Analysis

Clock ticking again on four-hour target for emergency departments

Emergency departments in England are being told they must start hitting the operational standard within a year.

Emergency departments in England are being told they must start hitting the operational standard within a year

Emergency departments (EDs) in England have been told they need to start hitting the four-hour target again by March 2018. Health secretary Jeremy Hunt has set the deadline following the announcement of extra money in the Budget.

According to Mr Hunt, the 2 billion for social care over the next three years and the 100 million to extend GP triage schemes before next winter provide the impetus hospitals need to reverse declining performance a view reiterated in NHS England's progress report on the Five-Year Forward View.

2 billion

extra funding for social care over three years

It is effectively a recommitment to the target after

...

Emergency departments in England are being told they must start hitting the operational standard within a year


From next March emergency departments in England have to reach
the four-hour treatment target. Picture: iStock

Emergency departments (EDs) in England have been told they need to start hitting the four-hour target again by March 2018. Health secretary Jeremy Hunt has set the deadline following the announcement of extra money in the Budget.

According to Mr Hunt, the £2 billion for social care over the next three years and the £100 million to extend GP triage schemes before next winter provide the impetus hospitals need to reverse declining performance – a view reiterated in NHS England's progress report on the Five-Year Forward View.

£2 billion

extra funding for social care over three years

It is effectively a recommitment to the target after comments earlier in the year in which Mr Hunt suggested the four-hour standard could be reviewed given the growing numbers attending EDs. The health secretary said he saw it as ‘critical’ for patient safety.

Not a measure of quality

RCN Emergency Care Association chair Janet Youd says he is right. ‘I’m pleased to see the retention of the four-hour standard. While it is not necessarily a measure of the quality of the clinical care, it does serve as a measure of the pressure in the entire system. We know that increased pressure and consequent extended ED length of stay is hugely detrimental to patient well-being.’

But how can hospitals get back on track? After all, performance against the four-hour target fell to around 85% in January – the poorest performance since the target was introduced in 2004.

£100 million

for GP triaging schemes for next winter

A detailed roadmap has been produced by NHS Improvement and NHS England. In a letter sent out to hospital chief executives in March, the regulators talk about making ‘concrete changes’ by freeing up hospital bed capacity and managing demand.

It goes on to urge hospital bosses to work with social care leaders to ensure the extra money announced in the Budget will be effective. It states this should free up between 2,000 and 3,000 beds a day across the NHS – which at the upper end is close to half the number occupied by delayed discharges.

Ways to free up beds

Meanwhile, the regulators stress the importance of using a variety of different measures to free up beds – some within the grasp of hospitals and EDs, and some not.

For example, they want the system known as GP streaming, where GPs determine who needs to be seen at the ED, to be extended; currently only about one quarter of EDs have such a system in place. They also want hospitals to provide more clinical advice and support to care home residents.

Other measures include the roll-out of evening and weekend GP appointments to cover 50% of the public by March 2018 and 100% by March 2019, while ambulance crews must continue their drive to ‘hear and treat’ and ‘see and treat’ more people without bringing them to EDs.

NHS England chief executive Simon Stevens says this should all help to kick-start a turnaround in performance.

85.1%

hit four-hour performance target in England in January

But how realistic is this? Ms Youd says the trajectory set out – 90% by September and 95% by March – is certainly ‘achievable’.

However, she fears finding the GPs to do the triaging ‘may be a challenge’ and questions whether the extra money for social care will be enough ‘given the population demographic changes’.

Royal College of Emergency Medicine president Taj Hassan takes issue with the GP triaging concept altogether. ‘It will only solve a small part of the problem and is not necessarily the correct way to spend extra money,’ he says.

Dr Hassan points out that the college has been pushing for co-locating services, such as GPs, mental health and specialist frailty teams around EDs, so patients can be treated rather than being sent elsewhere.

‘By creating a hub of services, patients can be swiftly directed to the treatment or service most appropriate for their needs without the need to travel elsewhere or book another appointment.

‘This is different to having a GP triage patients in an ED. While this is unlikely to have a negative effect on patients, it is also unlikely to make much of a difference to performance.’

Further question marks have been raised by NHS Providers. It published an in-depth review after the Budget looking at whether what is being asked of the health service is feasible. Its conclusion pulls no punches: it simply says it is ‘mission impossible’ as demand is rising twice as fast as the budget.

In terms of the four-hour performance, it predicts it will be ‘at best maintained’ but is more likely to ‘deteriorate’ due to the shortfall in ED funding of between £400 million and £600 million.

Pushing staff to meet the target in this environment will, the report states, place an ‘increasingly unsustainable burden’ on them.

‘The numbers don’t add up,’ says Chris Hopson, chief executive of NHS Providers. ‘Trusts want to deliver the standards, but they can only deliver if funding keeps pace with rapidly rising demand.’

How far will £2 billion go in social care?

The announcement in the Budget that adult social care is to receive £2 billion extra has come as a welcome surprise to many – most had not expected the government to be so generous.

But this does not mean it will solve all the problems. The money will be phased in over three years, with £1 billion to come next year and the rest to be spread across the following two years.

But this all comes after another year in which the Association of Directors of Adult Social Services (ADASS) says services have had to be cut.

According to the association, councils need to spend close to £20 billion in 2016-2017 but are £1 billion short. Before the Budget announcement, this shortfall was expected to grow to £2.6 billion by 2020.

The impact of the extra money is unclear. Council tax is rising and local authorities are able to retain more money from business rates, but direct funding from central government is being cut. It means, the association says, there is no guarantee that the extra money announced in the Budget will translate into extra spending.

How GP streaming helped one emergency department

The emergency department at Queen’s Hospital, run by Barking, Havering and Redbridge University Hospitals NHS Trust, Essex, introduced a GP triaging scheme last May.

It was originally for a six-week trial, but has proven so successful it has been made permanent and is now redirecting between 60 and 90 patients a day.

The scheme works by deploying a small team of specially trained GPs on the front desk of the ED to see all self-presenting patients who come in and then direct them elsewhere if appropriate. This can include to a pharmacy, self-care or back to their own GP.

The trust’s chief operating officer, Sarah Tedford, says she is pleased about how it has worked, with most patients dealt with by the GPs ‘within five minutes’.

‘It’s about directing patients to the most appropriate setting rather than waiting in a busy ED where they don’t actually need to be.’

 

Further information


Nick Evans is a health writer

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