5 Improving A&E performance |
The four hour standard
65. The four hour waiting standard requires all A&E
departments to see 95% of attending patients within four hours
of their arrival at A&E. It was the deterioration in performance
against this standard which prompted NHS England to launch a recovery
programme for emergency care. In evidence no witnesses argued
that the four hour target should be scrapped. Dr Clancy told the
Committee that it was a "process measure and not a quality
that other quality indicators were more useful in explaining how
well emergency departments are performing.
Mike Farrar explained that whilst the four hour standard was not
"a relevant clinical target" it remained a useful indicator
of overall performance.
Mr Farrar said:
The indicator gives you some sense of the flow
through a system. In clinical terms, obviously, if you present
with severe chest pain, waiting for three hours and 59 minutes
is not right. [...] But it tells you something about how patients
are able to be admitted and the capacity of the hospitals. It
also gives you a bit of insight into how many people are presenting.
Dr Cadigan sounded a note of caution, pointing out
that the target was prone to 'gaming'. He said when considering
the care of a patient in an emergency department:
At the point where there is inadequate capacity
and where the right thing to do is to hang on to someone for a
little longer in the A and E department, the four hour target
forces you to move themand forces you to move them to an
inappropriate placewhen it is clinically inappropriate.
66. In Chapter 1 we identified rising admissions
to hospital from the A&E department as a key indicator of
the changing nature of the workload of the A&E department.
In this chapter we examine how the flow of patients through a
hospital can adversely affect the work of an emergency department.
In oral evidence Dr Gerada linked these two factors and the issue
of emergency department staffing (also discussed in this chapter),
arguing that the four hour waiting target could drive unnecessary
admissions. Dr Gerada said:
With the four-hour target, there are what we
call zero-hour admissions, especially children or the elderly,
who are so-called admitted but not really admitted. [...]The problem
is zero-hour admissions either for observation or because there
is not somebody senior enough to make the decision whether or
not to discharge. That comes back to the original premise of the
College of Emergency Medicine: there are not enough senior doctors
in the emergency department to make decisions, hence you are clogging
67. In a well-functioning health system the four
hour waiting time standard would be met as a matter of course
rather than as an objective of policy. The four hour standard
retains its value as a basic measure of performance but it does
not provide a full measure of service quality. It is prone to
gaming and the key indicators of hospital performance should be
based on a broader assessment of patient outcome and experience.
Waiting times are certainly part of this, but not the whole of
ASSESSMENT OF PATIENTS
68. In publishing the evidence base for the Emergency
and Urgent Care Review, NHS England specifically acknowledged
Timely access is required from supporting specialties
to enable appropriate admission and transfer of patients to improve
patient flow within A&E departments.
Further information detailed within the evidence
base published by NHS England demonstrates the scale of the challenge
that they and the Department face in achieving this objective.
69. The Committee notes the case study of the South
Warwickshire NHS Trust which participated in the Health Foundation's
Flow Cost Quality improvement programme and reported in April
2013. The trust decided to analyse the flow of patients from A&E
through the hospital after examining the care of one patient who
spent an eight day stay in hospital. In this patient's case they
discovered that only 18% of his time in hospital had added value
to treatment and the rest of the time in hospital was regarded
as wasted. The trust
undertook a programme of substantial data analysis in attempt
to understand why the flow of patients was so inefficient and
to uncover the root causes of the problems. They found that:
As in many hospitals, most emergency patients
faced delays waiting for an initial assessment by a junior doctor.
Once assessed, they then had to wait for input from a senior medic.
There was also a lot of duplication (and therefore waste) in the
current system. Patients coming through A&E would be seen
by a junior doctor first, then by a registrar and sometimes by
an A&E consultant. This would often trigger a referral to
a specialist team.
70. The analysis found that there was a four-hour
delay between a patient arriving at A&E and then arriving
at an assessment unit or ward:
The consequence is that although two-thirds of
patients arrive during working hours (when senior decision-making
staff are available), they are not in the 'right' place by the
time the senior staff leave the hospital at 6.00pm. [...]
As a result of existing work patterns (8am to
6pm, Monday to Friday), on-take physicians and surgeons saw only
around a third of patients before 6pm on the day they presented.
71. In order to resolve this the team in charge
of reviewing patient flow hypothesised:
that if they placed senior clinical decision-makers
in the MAU (medical assessment unit), when patients presented,
they could improve the system dramatically. Having senior medical
staff available to assess patients earlier would get patients
onto their right care plan more quickly and efficiently.
The specialists also recognised that if they
visited the assessment units after their morning ward rounds (at
which time they would have discharged patients), they could 'pull'
patients from the MAUs to their specialist wards while beds were
72. The new system was trialled amongst cardiologists,
who discovered immediate benefits, and it has been extended to
other specialities including elderly care. In order to make the
new system work consultants had to accept extended evening and
weekend working. The presence of senior medical availability until
8pm instead of 6pm:
ensured that patients were being assessed and
put on the right care management plan on the day they presented.
It took major delays out of the process and, crucially, avoided
the need to 'store' patients overnight on the MAU.
73. The King's Fund analysis in southern England
supports the conclusions of the South Warwickshire study by emphasising
the importance of access to senior medical staff. They found:
In future rapid access to a senior opinion will
need to be the norm. Many hospitals are now developing Acute Medical
Unit (AMU) consultant job roles; specialists in assessment and
early treatment; networkers across the hospital to conduct patients
to the right speciality; and a source of advice to community based
clinicians to prevent admission.
In some AMUs the acute consultants are increasingly
used by GPs to provide advice on seriously ill patients, developing
closer working with the community. For example, in one trust the
AMU consultant on call takes GP referral calls directly, preventing
40% from being admitted.
74. The written evidence of the Royal College of
Physicians emphasised the principle that early senior review could
improve diagnoses, eventual patient outcomes and relieve pressure
within emergency departments. They said:
emergency departments should consider implementing
a rapid assessment and treatment (RAT) model in order to provide
early senior review for informed expert assessment, diagnosis,
care planning, end-of-life discussions, etc. Senior triage of
GP referrals to acute medicine has also been shown to be effective;
acute medicine consultant triage of GP phone referrals and the
introduction of medical ambulatory care pathways has seen a reduction
in community admissions by 37% in the areas served by Royal Derby
75. The evidence appears to be strong that quick
access to a skilled clinician, rather than laborious 'triage'
through an ascending hierarchy, delivers care that is both better
and more economic.
76. We recognise, however, that in practice there
is a difficult balance to draw, particularly when staffing pressures
are particularly acute in emergency medicine.
77. Acute trusts must learn from best practice
in the NHS. Patient flow studies by the Health Foundation have
found that pressure on emergency departments can be relieved by
restructuring the assessment of patients and changing working
patterns. The management and boards of Acute Trusts should take
responsibility for examining their own procedures and identifying
whether they are in line with established best practice. In evidence
Professor Willett told us that UCBs could help to examine best
We agree that UCBs are well placed to undertake this role; successfully
disseminating best practice across emergency and urgent care would
help to establish the value of UCBs.
78. Accessing early senior review of cases can
reduce duplication and accelerate the path of a patient through
the system. Senior clinicians are better able to balance risk
and make key decisions. We therefore recommend that trusts assess
the viability of implementing a rapid assessment and treatment
(RAT) model. Additionally we recommend that Acute Trusts operating
emergency departments explore the value of effective acute medical
units (AMUs) which are designed to incorporate rapid access to
senior specialist assessment and the swift development of care
plans including a plan for discharge.
79. The fifth system design objective of the NHS
England Urgent and Emergency Care Review is to improve the patient's
experience and outcomes by "ensuring early senior clinical
input in the urgent and emergency care pathway."
Improving access to senior clinical opinion can be achieved, in
part, by reforming staff rotas and reorganising the operation
of emergency departments. Nonetheless, the ability of emergency
departments to provide swift senior assessment is fundamentally
related to overall staffing levels.
80. The CEM argued in both written and oral evidence
that emergency departments do not have sufficient specialist consultants
to sustainably meet demand. The CEM's written evidence states
Workforce recruitment is in crisis. 3 successive
years of only 50% fill rates for Emergency Medicine trainees has
resulted in a 'lost cohort' of over 200 potential consultants.
This loss is permanent and irredeemable. In consequence all UK
departments have a significant shortfall in senior trainees, this
is compounded by hundreds of vacancies for other middle grade
and consultant posts. This shortfall affects service delivery
and patient safety on a daily basis. The College has called for
a minimum of 10 consultants per Emergency Department and 16 in
The pressure on those in post is relentless and
demoralising. Trainees and Consultants alike struggle to maintain
morale when forced to work within and deliver care on the very
margins of safety. This creates a vicious circle of recruitment
and retention failure.
81. The Emergency Medicine Trainee Association observed
in their written evidence that recruitment problems are also the
result of "a failure to retain quality EM (emergency medicine)
doctors at the middle grade level."
Dr Clancy went on to explain in oral evidence the relationship
between patient numbers and consultants:
we are seeing about 15 million patients and that
there are in the order of 1,400 consultants. That works out at
about just over seven consultants per department. We have grown
from four or so in 2007, so there has been an expansion, but there
are not enough trained emergency physicians to deliver the care
that the public expect.
82. The CEM's position is that a minimum of 10 consultants
are required in order to deliver a 16 hour presence in emergency
departments. Dr Clancy
told the Committee that existing staffing levels allow for a 12
hour presence 77% of the time on weekdays but only 30% of the
time at weekends.
Only 17% of emergency departments in England are able to provide
16 hour consultant coverage during the working week.
In order to fill the gaps in staffing rotas emergency departments
are making use of locums. Dr Clancy said that:
in the key decision makers the vacancy and locum
rate, other than consultants, is about 20% plus and the vacancy
in locum rate for consultants is about 17%. Trusts at the moment
are spending, on average, per trust £500,000 per annum in
locum costs for emergency departments. That is a resource that
really should be allocated in the future for substantive, trained
doctors who want to do this work.
83. In regard to the future sustainability of the
system Dr Clancy added that:
My major concern for the future of the emergency
care system is that not enough doctors want to do this work. [...]
The challenge that we face is: how do we value this work more
highly than we do now and how do we ensure that we attract doctors
into this work, which is difficult and hard, in a career that
is sustainable? We are asking doctors to work till they are 67.
This is tough work that many doctors migrate away from because
it is hard.
Referring not only to A&E consultants but acute
medicine in general, Dr Cadigan said that the specialty is not
seen as being glamorous because:
If you are a specialist, you tend to work in
a specialist unit: you work in an enclave that you can protect
in terms of the sorts of patients you accept into that unit; you
work with a consistent team; you work on a group of patients that
you know you can deliver good results to. When you move outside
that specialist environment into the general medical wards, the
wards into which patients are admitted if they do not have a very
specialist need, such as a heart attack or a stroke, you find
a very different environment where you cannot control the patients
coming in; where you do not work with a consistent team and you
may be working with a different group of doctors every day; where
neither the doctors nor the patients benefit from continuity of
care; and where, because of the pressure on beds, patients may
move from ward to ward four times within the first 48 hours. That
is not a professionally rewarding, safe or educationally good
84. Earl Howe commented that recruitment and retention
of trainees is a concern as "the lifestyle is pressurised
and there are fewer opportunities for private work."
His view is broadly in line with that of the Emergency Medicine
Trainee Association who described "brutal working patterns"
and reported that:
It is still not uncommon for some juniors to
work seven straight nights in EM usually under intense pressure
due to the high volume of patients in the department. It is clear
that these rotas are not sustainable over the long term and this
is a major reason for many excellent EM trainees are choosing
other specialties. [...]It is not uncommon for many ED junior
doctors to work through an entire shift without a rest break due
to the service pressures or having to cover due to gaps in the
They argued in their submission to the Committee
that the specific circumstances of emergency medicine demanded
a review of the junior doctors' contract to improve their terms
the new junior doctor's contract has to recognise
that the needs of acute specialties are very different from the
non-acute specialties and that 'a one size fits all' approach
will be disastrous for the specialties such as EM. We believe
that special attention should be paid in defining these needs
in terms of workable terms and conditions as well as appropriate
remuneration. Junior doctors working in EM currently get the same
banding as other specialties who do not work under the same intensity
or pressure as those working in EM.
85. In evidence Sir Bruce Keogh agreed with the contention
that the existing training regime attracts trainees to sub-specialities
which are of less value to patients and the NHS than emergency
care. Neither Earl Howe nor the Secretary of State would commit
to reforming training in order to drive trainees away from more
fashionable sub-specialities and into emergency care, and the
Secretary of State was more circumspect than Sir Bruce Keogh,
I am not aware that we are training too many
doctors in particular specialties. We need more doctors, full
stop. We need them in most specialities because of the increase
in demand across the system.
The Secretary of State said that it was Health Education
England's job "to make sure that we have the right number
of doctors and nurses with the right skills in the right areas".
86. There is a crisis in the recruitment and retention
of trainee emergency department consultants. At present trusts
are recruiting too many expensive locums at all levels of seniority.
The Department of Health, Health Education England and NHS England
must work together to address the concerns of trainees and make
a career in emergency medicine an attractive option for more young
87. The Committee does not believe that attracting
and retaining trainees is simply a question of improved remuneration.
Trainees will only join a specialty if they are convinced that
it offers the prospect of a career that is both professionally
and personally rewarding. It is important that Health Education
England and Local Education and Training Boards address these
issues in order to make emergency medicine an attractive career
88. In April 2013, the Health Foundation reported
on a programme implemented by Sheffield Teaching Hospital NHS
Trust which had been designed to improve the flow of elderly patients
through the hospital. The report highlighted the problems associated
with failing to discharge patients at the earliest opportunity:
A consultant analysed the notes of 23 of the
100 patients with the longest lengths of stay. This review highlighted
the difference between 'possible' length of stay (based on the
first definitive note by a geriatrician that the patient was medically
fit to be discharged) and 'actual' length of stay. The notes revealed
multiple points when the patients could have been discharged.
Opportunities were missed partly because the services involved
in discharge were unable to respond quickly enough, as a consequence
of a mismatch between capacity and varying demand.
As a consequence of delayed discharge, some frail
patients deteriorated while others were transferred to other parts
of the hospital. These transfers sometimes resulted in vital information
being lost, resulting in further deterioration, re-work and delay.
On average, patients spent four times longer in hospital than
was initially estimated by consultant geriatricians involved in
their care. It is estimated that these 23 patients received approximately
£471,960 of hospital care that could potentially have been
better spent on more appropriate care in their own homes, or on
residential or nursing care.
The case study reached the clear conclusion that
delays in discharge not only incurred unnecessary cost but could
also result in poor patient outcomes. Commenting on the pressures
in the system which have resulted in some emergency departments
failing to meet the four-hour target, Dr Cadigan said "it
is flow out of the emergency department that is one of the crippling
89. In oral evidence Mike Farrar told the Committee
that achieving smooth patient flow in hospital was dependent on
good discharge planning.
The NHS England A&E improvement plan acknowledges that problems
in A&E may the result of failing to discharge patients because
of lack of available community and social care services.
Indeed, UCBs have been tasked with working with local authorities
to ensure that early discharge options are available.
90. The King's Fund does not believe that delays
in discharge are entirely attributable to lack of available social
care provision, but they observe that:
Local authorities have tried to protect social
care budgets, but net expenditure on adult social care has fallen
in real terms for the past two years. The number of people receiving
publicly funded social care through local authorities has also
continued to fall - by 7 per cent in 2011/12 and by 17 per cent
since 2006/7. Over the same period, the number of people aged
85 years and over has risen by more than 20 per cent. A recent
survey of Directors of Adult Social Services by the Fund found
that transferred NHS money is being used to promote the closer
integration of care but in many cases it is being used to offset
general service pressures and councils are finding it much harder
to find savings that do not impact on the quality or quantity
of care (Appleby et al 2013).
The King's Fund do not, however, present evidence
that the challenges facing social care have directly resulted
in reduced availability of social care places to which patients
can be discharged.
91. The Foundation Trust Network presented anecdotal
evidence from its members of the problems facing acute trusts
in this regard. The FTN identified the relationship between delayed
discharge, reduced bed capacity and a lack of flexibility in hospitals.
Many hospitals are also facing an urgent and
growing problem of not being able to discharge patients in a timely
and effective way because of problems in social care stemming
from funding cuts due to reduced local authority budgets. FTN
members report problems with 'hospital back door' discharge, leading
to longer stays and higher bed occupancy rates. This rapidly leads
to problems coping with 'hospital front door' A&E admissions
as beds are not available. Small increases in patient acuity -
such as a 1% or 2% annual rise - can lead to increased admission
levels that hospitals find it very difficult to absorb when they
are running at or close to capacity.
92. Andrew Webster, Associate Director Integrated
Care at the Local Government Association (LGA), however, challenged
the notion that delayed discharges in relation to the availability
of social care were a major factor in the pressures afflicting
emergency departments. He told the Committee that:
Many people focus on the issue of whether people
are getting stuck in hospitalswhat are described as delayed
discharges. Those are actually going down, and those that are
attributable to social care are going down faster than those that
are attributable to things in the health system.
Additional written evidence submitted by the LGA
bears out this claim. They quote statistics published by NHS which
In 2012/13, the daily average number of delayed
transfers of care per 100,000 population (aged 18+) was 9.5, which
compares to 9.7 in 2011/12.
On delays attributable to local government going
In 2012/13 the daily average number of delayed
transfers of care attributable to social care per 100,000 population
was 3.3, which compares with 3.7 in 2011/12.
93. Earl Howe told the Committee that:
about 3% of total bed days are due to delayed
discharges, with approximately 2% of occupied beds being delayed.
So the long-term trend has reached a plateau. It is sticking at
around the level of 2,000 acute patients. Before, it was around
We, nevertheless, find the disparity between the
anecdotal evidence of health professionals and the formal statistics
striking. The Secretary of State conceded as much in oral evidence
and he observed:
when you talk to chief executives of hospitals
and to A and E departments and ask, "What is the biggest
single pressure that is a worry for you in terms of hitting your
95% target?", they say it is the lack of availability of
beds in the hospital to admit people who need admitting. In the
last few months, nearly all the chief executives have said that
they have approximately two wards full of people who could be
discharged but they are not able to discharge.
94. The national data available on delayed discharges
contradicts the evidence of clinicians and managers across the
acute sector. The Committee believes that the data is incredible
and we recommend that Ministers swiftly investigate the method
of data collection in order to understand whether the available
figures genuinely reflect the situation on the ground.
95. More important than national data collection
is the delivery of accurate information to local system managers.
The Committee received strong evidence to suggest that delayed
discharges were a significant threat to patient flow, and therefore
to care quality. We recommend that NHS England should require
each area's Urgent Care Plan to include an assessment of the impact
of delayed discharges on patient flows and a plan to address the
96. The NHS Confederation explained in written evidence
that the rationale for the 70-30 tariff split was to provide acute
trusts with an incentive to discover new ways to reduce demand.
Mike Farrar described this as having failed because it was "patently
clear that supply induced demand is not the driver here".
The NHS Confederation argued that what the marginal tariff has
achieved is to:
substantially increase the already intense financial
pressures on acute trusts with emergency departments. Furthermore,
the marginal tariff has in practice transferred the risk to providers
and has not created a shared imperative for commissioners to actively
engage with this issue and make changes to the local health service
which will tackle rising demand.
The Shelford Group observed in their submission to
the Committee that the problems associated with the marginal tariff
were compounded for the largest specialist hospital in a health
community. This is because patients in emergency departments "can
often by-pass other more local providers to receive care."
97. Discussing the way in which the tariff paid to
hospitals operates, Professor Willett told the Committee that:
At the moment, we pay a hospital by the admitting
diagnosis of the patient and the reference cost set by the average
length of stay across the country in previous years. The difficulty
is that [...] if the admitting diagnosis happens to be a urinary
infection but they have rheumatoid arthritis and had a stroke
last year and so on, what determines how long they stay in hospital
is not the fact they came in with a urinary infection but that
their dependency is much greater than someone who came in who
just had that infection.
The College of Emergency Medicine expressed frustration
with the existing arrangements noting that "resuscitation
is remunerated at a lower value than a routine out-patient attendance."
The NHS Confederation was critical of the way in which payment
systems have been developed and said that tariffs must be reformed
incentivise better joint working, more focus
on intervention and greater investment in community services,
all of which would relieve the pressures on urgent and emergency
They concluded that:
The various payment systems, such as tariff,
currencies and payment by results, have often been developed in
an ad hoc way to address various issues and plug particular gaps
across the system.
98. Dr Cadigan noted that that there are examples
of single commissioners successfully working with providers to
reduce admissions. He said that those that have achieved this
"have dismantled payment by results."
Further to this Dr Cadigan explained that:
one of the things that is done in successful
groups that have achieved integrated care [...] is that they have
reached mutual arrangements to dismantle standard payment by results
and gone for shared financial incentives and shared financial
99. The current arrangements for remunerating
A&E departments with only 30% of the tariff for activity over
2008-09 levels is no longer viable. The baseline is five years
old and does not account for, or reflect, the pressures that hospitals
face. As part of its review of the marginal tariff, Monitor should
seek options which minimise the twin dangers of perverse incentives
and excessive complexity. Incentivising all providers to direct
patients to the correct treatment option, however they come into
contact with the NHS, should be the over-riding priority.
59 Q 10 Back
Q 11 Back
Q 194 Back
NHS England, June, 2013, p 12 Back
Ibid, p 4 Back
Ibid, p 5 Back
Ibid, p 6 Back
Ibid, p 9 Back
The King's Fund, March 2013, p 26 Back
Ev 90 Back
Q 278 Back
NHS England, June 2013, p 6 Back
Ev 92 Back
ES 21, written evidence from the Emergency Medicine Trainee Association,
page 1 Back
Q 64 Back
Q 69 Back
NHS England, June 2013, p 51 Back
Q 73 Back
Q 64 Back
Q 67 Back
Q 287 Back
HC 119-iii, Q 278 Back
Ibid, Q 281 Back
The Health Foundation, Improving the flow of older people - Sheffield
Teaching Hospital NHS Trust's experience of the Flow Cost Quality
improvement programme, April 2013, p 3-4 Back
Q 9 Back
Q 43 Back
NHS England, May 2013, p 2 Back
Ibid, p 7 Back
ES 28, written evidence from the King's Fund, para 14 Back
ES 37, written evidence from the Foundation Trust Network, para
Q 167 Back
Ev 112 Back
HC 119-iii, Q 240 Back
Ev 100 Back
Q 74 Back
ES 40, written evidence from the Shelford Group, para 19 Back
Q 281 Back
Ev 95 Back
Ev 101 Back
Ev 101 Back
Q 55 Back
Q 91 Back