2 Sustaining and building on achievements
8. We congratulated the Department on the significant
progress made by trusts towards the achievement of the target
for 98% of A&E patients to be treated or admitted to hospital
within four hours. It used a mix of financial incentives and close
performance management, with support for those trusts requiring
it. The target was crucial to the improvements, and reduction
in variability, between trusts' performance. In line with the
national move to simplify and reduce the number of targets, central
planning and targets for A&E will however cease from April
2005. The Department said that time spent in A&E would feature
in the new Standards for Better Health. The Healthcare Commission
would inspect trusts' against this core standard, and trusts would
need to ensure that as a minimum they maintained performance at
98% within four hours.[9]
9. At the end of October 2004, around 70 trusts had
consistently achieved the weekly mark of 98%. Despite increases
in attendances at A&E the proportion seen within four hours
has improved month-on-month significantly (Figure 4), and
the Department was confident that the overall target would be
met by December 2004.[10]
10. In April 2004, the four-hour target was extended
to cover all NHS Walk-in-Centres and Minor Injury Units and their
performance was included within data on A&E departments to
show overall performance by all trusts providing emergency care.
This change in data recording has contributed to the rise in performance
by some acute trusts and demonstrates that sufficient facilities
and services in the vicinity or linked to A&E departments
help to achieve and maintain the 98% level.[11]
Figure 4:
Steady progress has been made by trusts as a whole, but major
A&E Departments are still some way behind the target
| Total attendances at all A&E, Minor Injury Units and Walk-in-Centres
| Percentage of patients who spent less than 4 hrs in A&E
| Attendances in major A&E Departments
| Percentage of patients who spent less than 4 hrs in A&E
|
| 2004-05 Quarter 2
| 4,556,695
| 95.9% |
3,381,219 |
94.6% |
| 2004-05 Quarter 1
| 4,502,578
| 94.7% |
3,377,850 |
93.1% |
| 2003-04 Quarter 4
| 4,009,142
| 92.7% |
3,059,698 |
90.6% |
| 2003-04 Quarter 3
| 4,027,622
| 90.8% |
3,106,667 |
88.3% |
| 2003-04 Quarter 2
| 4,347,584
| 90.7% |
3,281,186 |
88.1% |
| 2003-04 Quarter 1
| 4,132,497
| 89.9% |
3,217,931 |
87.3% |
Source: Department of Health performance data
11. During a visit to one central London A&E
department staff suggested that improving their performance from
96% was causing them great difficulties because of the type of
clients they receive, for example people with alcohol or mental
health problems and commuters who use the hospital as a drop-in
centre. The Department said the 98% target was not chosen arbitrarily
and certain categories of patient, such as those with mental ill-health,
were included in the clinical exceptions. It did not accept that
the costs of achieving these last two percentage points outweighed
the benefits. Each 1% improvement nationally was 160,000 more
people treated in less than four hours. Widely applicable process
changes, which had not required significant investment, had been
shown to work.[12]
12. These achievements mask differences for specific
groups of patients. Very few children or patients with minor injury
or illness spend longer than four hours in A&E. The elderly
and vulnerable adults are more likely to breach the four-hour
target, however, because of their complex medical and social needs.
Improvements to their care had nevertheless been made through
the use of clinical decision units and short stay wards where
the patients were placed in a proper bed and observed for longer
periods whilst appropriate treatment was given or care arranged.
The National Director for Emergency Access believed that further
improvements would be made, up to and after the December target
date, as he had been working with the National Director for Older
People's Services (the Older People's Czar) to provide better
managed community care programmes for the elderly and multi-disciplinary
health and social services teams within hospitals.[13]
13. One fifth of all attendees at A&E departments
require admission to hospital, and there remains room to improve
their experience as patients. Waiting for a bed on a ward and
obtaining a specialist opinion are the commonest causes of delay.
The Modernisation Agency provided tools to assist trusts in bed
management and improving access to specialist opinion in summer
2004, and the number of breaches of the four-hour target has been
reduced, from 50% to 23%, over eighteen months to August 2004.
Unless traditional working practices for admissions and discharges
are reformed in all acute trusts, however, bottlenecks will persist
in A&E and patients will not receive timely care.[14]
14. The need for diagnostic tests can be the reason
for bottlenecks in A&E. 11% of all stays longer than four
hours are the result of delays in diagnostic services. Despite
Departmental guidance to improve this situation by extending out-of-hours
x-ray services, the National Audit Office found that only just
over half the trusts responding to their survey had radiographers
available to A&E 24 hours a day. The Department felt it had
been addressing these problems since 1997, by initiatives such
as an increase in training places and "Return to Practice"
schemes for radiographers; but the world-wide shortage of these
staff had to be recognised as a contributory factor. Around 3,000
more radiographers will be employed in the NHS by 2008, but in
the short-term trusts have been encouraged to make use of new
technologies, such as digital imaging, and to expand the roles
of other staff to include initial interpretation of x-rays.[15]
15. Four hours may be too long, if for example patients
may be waiting a disproportionately long time for a simple procedure;
or staff may be pressured into making a premature decision about
patients who are in danger of breaching the four-hour target.
Currently average time is under two hours. The Department accepted
that the target had been a blunt instrument, but the aim was to
eliminate unnecessary delays for patients in A&E.[16]
16. Clinicians and managers generally agreed that
the target had focused attention on reducing delays, and consequently
had a beneficial effect on performance. In contrast to inpatient
services, where national performance data includes more than waiting
times, measures of the quality of care provided in A&E departments
and national benchmarking are very limited. The Healthcare Commission,
with the British Association for Emergency Medicine, has developed
three clinical audit tools for paracetamol overdose, pain in children
and fractured neck of femur (broken hip) which trusts can use
to audit their performance. The Department accepted that the lack
of an integrated patient record system made tracking the clinical
outcomes for patients who were transferred or discharged from
A&E difficult, but it was in the process of making the changes
to facilitate this flow of information.[17]
17. The increase in A&E attendances has intensified
the pressure on hospital staff. Despite extra funding for A&E
nursing posts and additional A&E consultants, the National
Audit Office found a gap between the number of positions and actual
complement in at least 84% of acute trusts in their survey. The
Department agreed that more staff, especially practitioners who
could act independently, were needed to maintain performance in
the future and to improve quality of care further. The strategic
health authority workforce development confederations conduct
annual exercises to plan consultant numbers, and to an extent
nurses and occupational therapists, but the Department does not
have a clear understanding of the reasons for the shortages of
certain types of staff employed in A&E.[18]
18. There is no accepted model for the numbers and
mix of types of staff in A&E departments for trusts to use
when budgeting for their emergency services, and so in many cases
current levels are based on historical baselines. With the increasing
use of 'See and Treat' for patients with minor injuries and illnesses,
and the need to meet the European Working Time Directive, more
input from senior clinicians is vital for A&E departments
to function effectively. The Department accepted as reasonable
the British Association for Emergency Medicine's calculation that
large A&E departments needed eight consultants if they were
to provide sufficient cover 24 hours a day, seven days a week.
A model based on types of patient, hour of the day and the time
needed for consultation by each 'decision making' staff group
is currently being tested. This model should allow trusts to develop
rotas to cope with demand and meet the needs of patients.[19]
9 C&AG's Report, para 1.5; Qq 6, 58; Ev 13 Back
10
Qq 3, 5 Back
11
C&AG's Report, para 1.6 Back
12
C&AG's Report, para 1.6 and Figure 4; Qq 4-5, 33-34 Back
13
C&AG's Report, Summary
para 7; Qq 7-8, 59 Back
14
C&AG's Report, paras 2.14-2.20; Qq 7, 9, 34 Back
15
C&AG's Report, paras 2.11-2.12; Qq 84-88; Ev 13 Back
16
C&AG's Report, paras 1.9; 1.16; Qq 15, 65 Back
17
C&AG's Report, paras 1.27, 1.29; Q 47 Back
18
C&AG's Report, para 2.25 and Figure 11; Qq 10, 66-67,
77-78 Back
19
C&AG's Report, paras 2.24, 2.27-2.28; Qq 14, 26, 79-82 Back
|
