Will momentous changes to the four-hour target in EDs affect patient safety?
NHS England remains tight-lipped about what will happen to four-hour target if new measures being piloted from April are successful
The four-hour emergency department (ED) waiting time target must go down as one of the most successful in the history of the NHS.
Introduced 15 years ago by the then Department of Health for NHS acute hospitals in England, it transformed the image of ED care from one where long waits (anywhere between 12 and 48 hours) were routine to a service that is probably the most trusted to see patients quickly.
In 2018, 21 million patients passed through EDs in England in under four hours up 23% since 2004-05.
patients seen in less than four hours in emergency departments in England in 2018
Source: NHS England (2019)
NHS England remains tight-lipped about what will happen to four-hour target if new measures being piloted from April are successful
The four-hour emergency department (ED) waiting time target must go down as one of the most successful in the history of the NHS.
Introduced 15 years ago by the then Department of Health for NHS acute hospitals in England, it transformed the image of ED care from one where long waits (anywhere between 12 and 48 hours) were routine to a service that is probably the most trusted to see patients quickly.
In 2018, 21 million patients passed through EDs in England in under four hours – up 23% since 2004-05.
21 million
patients seen in less than four hours in emergency departments in England in 2018
Source: NHS England (2019)
It is also notable that it is the one target to have remained almost identical in all four UK nations.
But that looks set to change.
Last year, prime minister Theresa May asked NHS England to look at how the four-hour target – and others – are working.
New measures
NHS England’s report on access standards was published earlier this month and recommends that new measures are piloted in EDs. These include:
- Time to initial clinical assessment.
- Time to emergency treatment for the critically-ill and injured, such as stroke, heart attack, major trauma, severe asthma and people experiencing severe mental health issues.
- Average time spent in the ED for all patients.
NHS England now plans to trial the new measures for six months from April in 10-20 trusts.
It is not yet clear what the targets will be set at, although it appears a goal of 15-30 minutes may be set for initial assessment, while critical cases will be expected to start treatment within an hour.
‘There are days you hate the target’
Justin Walford, a senior practice development nurse in the emergency department (ED) of the Royal Sussex County Hospital in Brighton, is honest enough to admit that he does not always like the four-hour target, but recognises it as a necessary evil.
‘There are days you come in as an emergency nurse and hate the four-hour standard. It puts additional pressure and stress on you, but you know it is important for patients.
Increase in mortality
‘Previous research has highlighted waiting longer in EDs means patients can have the worst outcomes and an increase in mortality.
‘I fear if the standard goes, patient length of stays will increase.
‘It signifies it is no longer important.
‘In ED if we’re waiting for results to come back or a review by a specialty. Not having the target means they may focus on other areas – not the patients in the ED.’
Downgrading bad for patients
NHS England has remained tight-lipped about what will happen with the four-hour measure and whether it will even continue to be recorded if the pilots prove to be successful.
But whatever happens, the Royal College of Emergency Medicine (RCEM) believes any downgrading will be bad for patients.
RCEM president Tajek Hassan says the four-hour target is ‘absolutely mission critical’ and describes what is being planned as ‘disappointing’.
43 months
in a row the four-hour target has been missed in England
Source: NHS England (2019)
He believes the proposals represent a ‘dismantling’ of the four-hour target, which will lead to ‘crowding and delays in assessments, antibiotics and pain relief’.
‘It may send us back to the dark days of patients spending 12, 24 and 48 hours in hospital corridors,' he says.
He wants the target to be kept alongside the new measures – a move which was recommended in the college’s report on quality indicators and system metrics earlier this month.
Poorer outcomes
Dr Hassan also highlights that a 2017 health and social care review in Scotland – led by Sir Harry Burns – came to a similar conclusion, linking the four-hour target to research showing long waits in EDs increased the chances of poorer outcomes, longer hospital stays and, ultimately, death.
‘It may send us back to the dark days of patients spending 12, 24 and 48 hours in hospital corridors’
Tajek Hassan, president of the Royal College of Emergency Medicine
No other part of the UK is planning on changing the four-hour measure at present.
NHS England medical director Stephen Powis, who led the clinically-led NHS review, has defended the move.
He says it is the ‘right time’ to look at the targets given how emergency care has changed with the introduction of specialist centres for strokes, trauma and heart attacks.
‘The current target does not distinguish between the hospital where 10% of its patients wait five hours to complete their treatment versus the hospital where 10% of its patients wait 11 hours’
Stephen Powis, NHS England medical director
Professor Powis believes the changes will speed up care for these patients, while the introduction of an average measure should help ensure other patients do not wait longer than they do now. He also says it is a better way of measuring performance as it means every wait by a patient matters.
‘The current target does not distinguish between the hospital where 10% of its patients wait five hours to complete their treatment versus the hospital where 10% of its patients wait 11 hours.’
Gaming tactics
Royal College of Nursing Emergency Care Association chair Janet Youd says it is clear there have been some perverse effects created by the target, but she is adamant it should not go.
‘We have certainly seen some gaming – patients moved at the last minute to inappropriate areas or admitted ahead of those with greater clinical need to prevent a “breach”.
‘And we know it is not a guarantee of quality, but the four-hour target certainly has its place. It is a measure of flow, which is essential to patient safety.
18%
of hospital admissions from the emergency department take place in the last ten minutes before the four-hour mark in England
Source: NHS England (2019)
Ms Youd also thinks the proposals put forward need carefully thinking through, pointing out quick treatment standards may also be needed for other patients, such as older patients with dementia or those who have experienced fractures.
Regardless of what is eventually decided, she says the changes must also be accompanied by greater investment.
‘With current staffing levels I am not sure we will be able to achieve these new targets anyway.’
Is the four-hour target impossible to meet?
While more patients are being seen in four hours, it is also true that more patients are waiting longer than that.
The result has been a decline in performance against the four-hour target across the UK. Emergency departments are expected to admit or treat and discharge 95% of patients in four hours.
But no UK nation is achieving that. February 2019 saw the single worst set of figures recorded in England since the target was introduced in 2004, with under 85% of patients admitted or discharged within four hours.
It is now more than three years since the target was last hit, while one must go back even further in Wales and Northern Ireland.
Scottish struggle
Even Scotland, traditionally the best performer of the UK nations, has started to struggle. The target was last hit there in August 2017.
In fact, the situation has got so bad that there are hardly any individual services meeting the target either.
Latest figures show just three did in England, while if you exclude the Scottish islands, only three boards in the rest of the UK managed to.
NHS Confederation director of policy Nick Ville says hospitals were simply being ‘overwhelmed’.
‘Staff are being placed under considerable pressure and everyone knows this cannot go on.’
Further information
- NHS England (2019) Clinically-led Review of NHS Access Standards: Interim Report from the NHS National Medical Director
- The Royal College of Emergency Medicine (2019) Improving Quality Indicators and System Metrics for Emergency Departments in England
- Scottish Government (2017) Review of Targets and Indicators for Health and Social Care in Scotland
Nick Evans is a health writer
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