The state of Urgent and Emergency Care and the question of the Clinical Review of Standards

This newsletter is England focused because it deals with the performance metrics debate. I hope it will still be of interest to those of you in the devolved nations struggling with many of the same issues. I last wrote to you specifically about the Clinical Review of Standards when the consultation document was published and since then we have been in an accountability vacuum. NHS England publishes the Urgent and Emergency Care metrics monthly, documenting the deteriorating position of our Emergency Departments and ambulance services but without any articulated strategy as to how to link elective recovery and pandemic recovery to recovery of unscheduled care. In the last couple of weeks there has been quite a lot of mention of the four-hour standard with some even saying that it has already ‘gone’ and the Secretary of State saying in the Health and Social Care committee this week that the four-hour target is the ‘wrong target’.

I am very pleased that we are back to having some conversation about Urgent and Emergency Care but am deeply worried that the focus is on the metric rather that what actions are needed to have a functional emergency care system. Measurement alone does not improve performance or quality of care.

When the four-hour access standard was brought in (2004) we saw a big investment in Emergency Departments. At the time the principal problem was Emergency Department capacity to manage patients. We did not have enough space or enough staff. Not everyone in Emergency Medicine was keen on the standard and as patient numbers increased and capacity was again outstripped many campaigned against it saying it distorted clinical priorities. RCEM supported maintaining the standard as it was good at highlighting systems under pressure, increasing staff numbers and our service profile high. As things got more and more difficult, we saw increasingly perverse ways of improving target performance because Trust CEOs were being held to account for this single number. Some lost their jobs. Gaming of the target or any target comes about when the culture is to try a hit the target in isolation and so miss the point about patient care. Inappropriate actions included, in recent years, a demand to see walking in/ low acuity patients as a priority over Majors patients, adopting nearby urgent treatment centres and minor injury units so that their patient numbers could be added to the denominator or inventing ‘off the clock’ areas where patients could move to and their wait for definitive care go untimed and unpublished in performance data. Only rarely does action get taken for the most vulnerable patients, often the elderly, those waiting admission and then only when those patients looked like they might breach the awful ‘Decision to Admit’ plus 12 hours standard. We are all aware of the admission pattern, documented by many reviews, of admission facilitated miraculously at 3 hours 59 minutes. We are also aware that organisations which had much celebrated good four-hour performance, but actually had long delays for bed admission hidden by ‘interesting’ Decision to Admit’ rules.  There is no question though, that the simplicity and reassurance of the metric meant it is a successful offering to the public. The problem is that the four-hour access standard is a very blunt instrument as it does not differentiate between the patient with a rash, cut finger or broken ankle and a patient needing resuscitation and intensive intervention to maintain life. The time offering to the low acuity patient population along with inadequate investment in community services has driven some of the use of Emergency Departments by patients who could receive care elsewhere. The expansion of our own capability and capacity was not matched by other parts of the Urgent and Emergency Care system and we have become the bottleneck again simply because problems outside our area of the patient journey have not been managed while the four-hour access standard was touted as a whole system metric it never really was – it remained firmly an Emergency Medicine problem whatever people said.

In June 2018 the Prime Minister asked NHS England for a clinically led review of the NHS access standards to ensure they measure what matters most to patients and clinically. There are four workstreams: Mental Health; Elective care; Cancer care; and Urgent & Emergency Care. From Spring 2019 RCEM engaged with the CRS because we recognised that the performance framework was no longer driving meaningful improvement and did not work for some of the patient care we wanted to deliver in our departments. Not engaging would not have stopped the review happening. The process gave us the opportunity to discuss how we deliver patient care and alternative ways of making flow from the front door of the hospital better.  

The CRS had a bumpy start when the proposed new standard was the mean time in the emergency department for all patients. We pointed out at once this was not going to work. Fourteen pilot sites were identified – there was a mix of types of departments and a spread across the regions. The sites had several possible metrics to collect but the whole project was confusing, overly secretive about the data and no consistent instructions about how to implement the proposed framework. It seemed that the pressure was off from the four-hour standard, but there was no accountability line. These departments have remaining in a vacuum on performance ever since.

Eventually after many meetings the Clinically led Review of Standards focused on how we could improve the care of the sickest patients – most often the patients who are unwell enough to need admission as well encourage improvement across the whole patient journey. RCEM’s position was always that the replacement of the four-hour standard only made sense if we could find something better. All standards have unintended consequences and the four-hour standard suffered from not measuring total waiting times, not differentiating between severity of condition, and measuring a single point in often very complex patient pathways. Worse still was that once a patient had breached four-hours there is not further trigger point until Decision to Admit plus 12 hours.

The CRS bundle proposal went out to public consultation in Dec 2020 and RCEM responded to that consultation. The report of the consultation was published in May 2021. The full bundle covers the full patient journey but recognises the different needs of admitted and discharged patients by disaggregation of the metrics.

Pre-hospital

  1. Response times for ambulances
  2. Reducing avoidable trips (conveyance rates) to Emergency Departments by 999 ambulances
  3. Proportion of contacts via NHS 111 that receive clinical input

A&E

  1. Percentage of Ambulance Handovers within 15 minutes
  2. Time to Initial Assessment – percentage within 15 minutes
  3. Average (mean) time in Department – non-admitted patients

Hospital

  1. Average (mean) time in Department – admitted patients
  2. Clinically Ready to Proceed

Whole System

  1. Patients spending more than 12 hours in A&E
  2. Critical Time Standards 

Are these metrics better? As a group they certainly describe the patient journey better and they do address directly very long waits. 12 hours is too long and RCEM argued for 6 hours or the APD6 of GIRFT – Aggregated patient delay metric.

The effect of long delays in the ED for admitted patients are starkly shown in the recent paper published in the EMJ. The data in this paper was collected while the four-hour standard was in place and any conclusion must again recognise that the standard is not the issue but how organisations deliver patient care.

(Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency department and all-cause 30-day mortality Emergency Medicine Journal Published Online First: 18 January 2022. doi: 10.1136/emermed-2021-211572)

Four-hour performance data includes all patient timings equally. Conversion rates vary quite widely as shown in the Emergency Medicine GIRFT report published in September 2021 – mean 30.4% (range 16-43%). This means that high numbers of low acuity, not admitted, patients can hide the potential for serious patient harm from long waits. The problem with just focusing on the four-hour access target is we cannot dissect out where the problems are for these vulnerable patients who need admission. What the excellent paper does tell us very clearly is that long lengths of stay are bad for patients. We need to call out these delays and get action to eliminate them. There is an argument that these long delays would be eliminated if we got back to achieving the four-hour standard. That makes sense in some ways but less so when we are honest about what we were actually achieving and would miss the chance to transform the patient journey by collaborating with other teams in the hospital as well as primary care.

The hope behind the CRS is that by disaggregating data, identifying when a patient should move on in their journey – Clinically Ready to Proceed – and calling out transparently the longest stays – 0-12 we could see some real change. We would have a performance framework that would drive improvement again but this time across the whole system.

The problem is that we really need the full bundle for this to work and it is complicated and not easy for a politician to communicate. But should that really be the deciding factor in doing something that should improve patient care by eliminating long stays? A major worry at this point is that we are in a very different place with Emergency Department performance from when the CRS process began back in 2019. The four-hour standard performance is bad but it is the very long stays, whether measured by 12-hour DTA or 12 LOS that are the greater worry

In December 2019 Type 1 four-hour performance was 68.6%, December 2020, 72.1% and December 2021 61.2%. DTA 12-hour breaches have gone from 2347 in December 2019, to 3745 in December 2020 and 12,986 in December 2021. These are the sickest patients and those requiring mental health bed who are trapped in our departments, and it is our duty to advocate for their care.

We are now in a much more difficult position and finding appropriate thresholds that would drive change quickly is going to be hard. The next worry is that there is no timeline for getting action. There is a great deal of politics involved in decisions about healthcare at the moment and we are only one of the interested parties in all of this. We also must recognise the risk of getting some of the bundle and not all and how we would feel about that. The reason for this concern is that there have been two guidance documents published in the last few months that refer to some of the bundle metrics. In September 2021 the UEC Recovery 10 Point Action Plan was published instructing local providers to ensure initial assessment within 15 minutes of arrival, review the proportion of patients staying in Emergency Department for more than 12-hours, stating they should not stay longer than 12 hours from time of arrival and that patients should have CRtP (Clinically Ready to Proceed) recorded and should move on in 60 minutes.

NHS England published a document on 24 December 2021 called 2022/3 Priorities and Operational planning guidance.  The priorities in UEC were eliminating 12 hour waits (and no more than 2%) in Emergency Department, and an ask to improve all ambulance response standards by minimizing handover delays.

The mention of 2% is the first time any threshold for any of the metrics has been published. RCEM’s ask is 0% but it may be useful to think about this standard stretching to other unscheduled care areas, for example Same Day Emergency Care. A shared standard across the landscape could be transformational. We have discussed the publication of guidance documents at RCEM Executive and Council recognising that we will need to have a position on the implementation of the full bundle, some but not all the bundle, parallel measurement of the four-hour standard and any proposed thresholds as things progress (or don’t). Our core position is that we need to be working in an accountable framework that promotes patient safety and high-quality care.

For now, these guidance documents should be the basis of local organisation action plans and we must hold NHSE to account to make sure this is happening. We must see some action to improve the situation we and our patients currently find ourselves in. In the very short term RCEM continues to ask that the collected 0–12-hour data is published as we believe this is critical to getting Executive teams to focus on the longest stays.

The RCEM position has been that the Emergency Care system is in crisis – before the pandemic and now even more so. We need to see a commitment to transformation. A standard does not produce the outcome, it is the culture of commitment to value and meet the standard that makes the difference. We have hoped that the CRS could be the agent of change by reinvigorating discussions within the service about what matters, how we create flow and how we prioritise our sickest patients while still providing a high-quality service for those who need emergency care but not an admission.

What happens next, we don’t know but we must keep talking. To some extent I don’t mind what the metrics are as long as they are clinically meaningful, cannot be gamed to hide serious patient harm and are used to drive improvement in our battered services. Given how difficult things are for the whole NHS this is quite a challenge, but we must grasp the opportunity to make a difference for our patients and our staff.

by Dr Katherine Henderson, President of the Royal College of Emergency Medicine

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