NHS chiefs look to scrap four-hour A&E maximum waitIvy Madziva
Patients with minor ailments would miss out in change to targets.
NHS bosses are considering a shake-up of A&E care that could lead to patients with only minor ailments no longer being guaranteed that they will be treated within four hours.
Under the plans being examined, people with non-urgent medical needs would be advised to seek help at a GP surgery, walk-in centre or pharmacy instead – or face a long wait in A&E.
Senior figures in the NHS are also looking at bringing in extra targets to complement the four-hour waiting time standard under which the most urgent cases are seen within an hour.
Sources close to NHS England’s development of its forthcoming longterm plan acknowledged that any change to the target, which is popular with patients, risked creating a backlash. Government ministers, in particular the chancellor Philip Hammond, have made clear that they do not want to see changes to the NHS’s time-bound guarantee to patients. They do not want to approve anything that would lead to accusations of the ditching of the four-hour target.
The Royal College of Emergency Medicine (RCEM), which represents A&E doctors, has also signalled its opposition. It warned that asking some patients to seek care elsewhere or wait a lot longer than at present would not deter those with minor injuries and illnesses from arriving – and could lead to more aggression and violence by fed-up patients.
“The idea is that as part of a relaxation of the A&E target people with not much wrong with them, like a stubbed toe, would no longer automatically be treated within four hours; that for them the clock would not necessarily start ticking,” said one well-placed source. “This would apply to ailments that could be treated in a walk-in clinic or GP surgery.”
A small team of experts led by NHS England’s medical director Prof Stephen Powis is looking at options for reworking the health service’s key treatment targets, including the duty of hospitals to give patients non-urgent operations within 18 weeks, as well as the four-hour A&E wait.
The target currently applies to everyone who turns up at A&E, regardless of how unwell they are. When Labour introduced the measure in 2004, hospitals had to treat 98% of patients in England within that time. The coalition government then reduced the target to 95% in 2010.
However, hospitals in England have not met the 95% target since July 2015 and the relentless rise in demand for care means the performance of some has sunk as low as 50% as the NHS has faltered. Doctors complain that for some patients A&E has become an easy place at which to seek speedy care for a small problem instead of waiting what can be several weeks to see a GP. A&E is meant for accidents and emergencies, “not anything and everything”, they say.
“There’s a discussion involving NHS England and NHS Improvement [the service’s financial regulator] about what needs to happen with the targets so that they can be got back on track,” said a second source. “They want to look at targets in a way that would move the goalposts, to make them more readily deliverable … by moving the targets.”
Possible changes to both the A&E and planned operation targets are being discussed with reference to a new focus on “clinical prioritisation”, under which the sickest would be seen fastest under both pathways to care. A&E arrivals are already prioritised by a triage nurse, on a one to five scale of need. But the new system, if adopted, would make that much more stringent and routine.
Last week NHS Improvement warned that the rising demand for care, which is closely linked to an ageing and growing population, means it could take until 2023 for hospitals to start hitting targets again. The long-term plan “will set out a clear path to recovery” and initiate “a reset on performance over the next five years”, the agency said. But one hospital trust chief executive, speaking on condition of anonymity, said that demand coupled with widespread financial and staffing problems across the NHS meant that the plan was overly optimistic. “I can’t see a time when we are going to hit either the four-hour A&E target or the 18-week target for planned care ever again,” he said.
Dr Taj Hassan, the RCEM’s president, said a “woeful lack of resources to adequately staff and support emergency departments and increasing demand, combined with lack of acute bed capacity, has led to the present mess, with awful crowding in emergency departments. This is compromising basic safety and ability to deliver dignified care. It is adding risk of harm to patients and leading to increased attrition amongst staff.”
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