What does the NHS England review of waiting times mean for accident and emergency departments?

The accident and emergency (A&E) 'four-hour' waiting time standard was first announced nearly twenty years ago in the NHS Plan (Department of Health 2000). Over the past two decades it has arguably been the highest profile NHS target and a barometer for the performance of the health service as a whole. 

But things have changed in the past twenty years. The way care is delivered has evolved, with some patients who would once have been admitted to hospital overnight now being able to receive more lengthy investigation and treatment in A&E before being discharged home. And of course performance against the A&E standard has dramatically declined over the past five years as funding and staffing pressures took their toll. 

It was both unexpected but unsurprising then that when the Prime Minister announced a new five-year funding deal for the NHS in June 2018, she also announced a review of the main NHS performance targets, stating 'we would like clinicians to confirm the NHS is focused on the right targets…which incentivise the best care and outcomes for patients'.

This review, led by the NHS England National Medical Director Professor Steve Powis, published an interim report in March 2019. The report proposes substantial changes to how waiting times for A&E, routine hospital, cancer and mental health services will operate in future.

What's been proposed?

The current standard is for 95 per cent of all patients attending an A&E department to spend no more than four hours before being admitted to hospital, discharged or transferred. This includes major consultant-led A&E departments, minor injury units, walk-in centres and urgent treatment centres.

Under the new proposals, three new waiting time targets will be introduced. First, the total time patients spend in A&E departments would still be measured, but the average (mean) waiting time would be used as the main measure rather than the percentage of patients who wait under four hours.

So far, NHS England have not said what the new target for average waiting times will be. But students of NHS history will remember that the NHS Plan (2000) said, ‘By 2004 no-one should be waiting more than four hours in accident and emergency from arrival to admission, transfer or discharge. Average waiting times in accident and emergency will fall as a result to 75 minutes.'

The clinical standards review has also proposed two other new targets: how long patients wait before being clinically assessed after they arrive in A&E, and how long the most critically ill patients – such as patients experiencing a stroke – wait before a package of their treatment is completed.

Here we run through some of the issues the review raises for A&E departments.

1. The current A&E target does not tell the whole story of how long patients are waiting

Figure 1: The four-hour A&E target has a powerful effect on how patients are treated in A&E

_{Source: NHS Digital and NHS England, 2017/18
Notes: Data are for all types of A&E (major, specialist, urgent treatment centres) commissioned by the English NHS.}

There have been debates about the unintended consequences and perverse incentives of the four-hour A&E target ever since it was introduced. For example, the target is blind to how long patients wait once the A&E standard is missed. This doesn’t mean that A&E staff simply 'give up' on delivering timely care for patients who have breached the four-hour standard, but it does mean that the waiting times for these patients are obscured from the key national figures. And we know from other reports that long waits in A&E departments for some patients, such as those with acute mental health symptoms, have been rising in recent years.

The pressure to meet the target and its binary pass/fail nature has also been associated with a spike in admissions to hospital as the four-hour mark approaches, with the implication that at least some of these admissions could have been avoided if more time was available to clinicians and managers to plan an alternative course of action (Figure 1).

NHS England hope that moving to an average waiting time will even out the current cliff-edge of admissions before four hours and put a new focus on patients who spend far longer than four hours in A&E departments. This is because the average waiting time in the department will, by definition, be affected by how long each patient waits in A&E – not simply whether their wait was over or under four hours.

2. But will a new focus on average waits in A&E reduce longer waits?

Figure 2: A&E departments can still have the same average waiting time, despite having very different patterns of individual waits for patients

^{Notes: Each chart shows 100 fictional attendances, with the waiting times for each attendance set to create an average waiting time of 173 minutes.}

The intentions to 'unhide' the hidden long waiters in A&E departments and remove the tyranny of the four-hour cliff edge are sound. But, it is possible that A&E departments could still hit the new target while missing the point.

Figure 2 shows four – thankfully fictional – scenarios that are varied in their dysfunction but still share something in common: in each of these departments the average waiting time is 173 minutes. The underlying point these charts make is that a single measure of performance, whether it is an average wait or the percentage of patients seen in four hours, is never enough to tell the story of what is really going on within an A&E department. That is part of the reason why NHS England has also proposed new targets for how long patients wait in A&E before being initially assessed and treated.

But the current review of NHS targets could adopt more of the lessons from previous reforms. Recent changes to ambulance response time standards introduced separate measures of both average waiting times and longer waiting times. And the last review of A&E standards introduced measures such as the rate at which patients returned to the department within seven days of discharge – placing a focus on delivering the right care, not only rapid care. In both of these cases, care was taken to ensure that average waits were part of, rather than the main, measure of how services are performing.

3. Average A&E waits can be a complex measure

Figure 3: There is substantial variation in average waits across NHS organisations

^{Source: NHS Digital and NHS England, 2017/18
Notes: Data are for the 134 trusts that have at least one Type I (major) A&E department.}

The fictional scenarios in the previous section all had an average waiting time of 173 minutes for a reason – 173 minutes is the average total time patients spent in A&E departments in 2017/18 (NHS Digital and NHS England 2018). But as you might expect, there is considerable variation in average waits across different A&E departments (see Figure 3). And as other colleagues have shown (Scobie 2019), some of the high performers on the current A&E target may not remain high performing under the new standard – which could lead to some rapid changes in performance league tables.

And while the four-hour standard has its detractors, it has one clear superiority over the new average waiting time measure: the four-hour target is simple. Regardless of the time of day, how full the hospital is, the medical needs of the patient – every individual attending an A&E department is given a pledge – enshrined in the NHS Constitution – that they should expect to spend no more than four hours in A&E¹ . For both patients and staff in an A&E department, holding an ‘average wait’ in your head as the measure of performance is likely to feel more diffuse and complex than a four-hour wait.

The simplicity of the four-hour target also brings some operational clarity in how hospitals are run. The four-hour mark is important because it is, pardon the expression, a backstop. It can create a sense of urgency that helps to lubricate the gears in hospital when a patient needs to be admitted or transferred. And once this backstop is removed, it is unclear what will happen to waiting times.

This is part of the tension the Clinical Standards Review is trying to resolve. Replacing the four-hour target with an average waiting time target could lead to a loss of clarity and simplicity but it brings with the opportunity for greater flexibility and local decision-making on how services should be delivered.

4. Should all types of A&E department be treated equally?

Figure 4: Waiting time performance has deteriorated most substantially in major A&E departments

_{Source: NHS England}

Over the past decade, performance has fallen away in major A&E departments even as other types of A&E – such as dental and eye hospital A&Es or minor injury units and walk-in centres – have sustained their high performance (Figure 4). This means that at the height of winter in January 2019, only 2 of the 134 major A&E departments met the four-hour standard (Figure 4).

Figure 5: Only a minority of major A&E departments meet the national waiting time standards, January 2019

_{Source: NHS England, January 2019
Notes: Performance data are reported on the basis of organisations rather than individual A&E departments. For example, a hospital trust that operates major A&E services on two separate sites and which also has an eye hospital would appear only twice in these data – there would be one figure for the overall performance of the hospitals major (Type 1) A&E services, and a separate performance figure for the specialist (Type 2) A&E department. In January 2019, data were reported for 134 trusts with major (Type 1) A&E departments, 32 trusts with specialist (Type 2) A&E departments, and 197 organisations providing urgent treatment centre services (Type 3 A&E departments).}

The review proposes that the new average waiting time in A&E standard will apply to both major and minor A&E departments. But because of the differences in how these departments operate and the types of patients they see, should the NHS England review explore separate targets for different types of department?

Perhaps one reason why separate targets were not proposed for major consultant-led A&Es and minor A&E departments, such as walk-in centres and minor injury units, is because this would paint an overly simplistic picture of how A&E services are organised and delivered. It is not easy to identify ‘minor’ patients from ‘major’ patients within larger A&E departments that offer both services – though this may be possible in the future through the new [Emergency Care Data Set](https://www.rcem.ac.uk/docs/Informatics/ECDS Flyer.pdf). And there is already a contentious industry of how the activity and performance of minor A&E departments is pooled with major A&E departments. So rather than atomising things further by introducing different targets for different types of A&E you can see why NHS England has opted for a more simple approach of a headline waiting time standard that applies to all types of department.

Figure 4 also suggests a final point – as is traditional for publicly availably A&E data, it presents data by organisation (or NHS trust) rather than for individual A&E departments. Although ‘NHS trusts’ are often used as the unit of planning, performance and discussion in NHS health policy circles, I am yet to find a member of the public who is more interested in the aggregate performance of their local NHS trust than the performance of their local A&E department. The Clinical Standards Review makes frequent reference to measuring what is most important to patients. One area it could further explore is whether it is now time for the NHS to start routinely publishing information for individual A&E departments as well as NHS trusts.

5. Should admitted and non-admitted patients have the same waiting time targets?

More debate might be needed on whether total waiting times should still be measured in aggregate for all types of A&E patient. Patients who need to be admitted to hospital often wait longer in A&E and are more affected by the spike in activity that occurs just before the four-hour target is reached (see Figure 6). In part this is because these patients can need more investigation and treatment in A&E. But, especially in recent years, it is likely that these long waits are due to delays in finding an available bed in the main hospital.

As this is one of the key issues driving long waits in A&E departments, NHS England’s review could promote greater use of the aggregate patient delay measure developed by senior emergency medicine clinicians. In short, this measure looks at the total time beyond four hours that patients spend in A&E waiting for admission (or the average wait for patients who have already breached the four-hour target). Using existing data in this way places a clearer focus on waiting times for admitted patients and helps unhide some of the long waits which are currently hidden by the pass/fail nature of the four-hour standard.

Figure 6: Patients have very different patterns of A&E waits if they are admitted to hospital

_{Source: NHS Digital and NHS England, 2017/18
Notes: Data are for all types of A&E (major, specialist, urgent treatment centres) commissioned by the English NHS.}

6. What the public thinks about all this is up for debate

The NHS England review makes several references to a recent Healthwatch survey of people's views on A&E waiting times, and notes '…patients themselves do not identify total time in department as a priority'. But other polling work has shown that waiting times are the main cause for concern for patients visiting A&E departments, and that patients are in favour of keeping the four-hour standard (see Figure 7).

Figure 7: It is not easy to determine what the public think about the A&E target

_{Source: Ipsos Mori polling for the Health Foundation and BBC News (2017). Ipsos Mori poll on concerns show results that received mentions of 10 per cent or more.}

Now, NHS England and Healthwatch are not suggesting that waiting times are not important to patients – they are arguing that patients care about more than just the total time they spend from arrival to departure from A&E. These include the time patients spend anxiously waiting from arrival to first being seen and clinically assessed, and the time it takes for treatment to start – hence the new targets for time to initial assessment and treatment NHS England has proposed.

But the point is that the public and patients need a chance to have their meaningful say on the proposals. NHS England has committed to a public consultation before changes are made, but it is unclear what form this public engagement will take, and what question is being asked of the public. The proposed changes to these targets are changes to the pledges the NHS has given to patients in the NHS Constitution. To avoid risks that the changes are a fait accompli, and something done to patients rather than with patients, it would be helpful for NHS England to provide more details on how patient feedback will be used during the pilots of the new standards, and how meaningful consultation with the wider public will be achieved.

7. Will the proposals make a difference to patient care in A&E?

There has been an interesting mix of reactions to the NHS England proposals to change A&E standards. Some people I have spoken to think the changes will have a substantial impact, while others think there will be almost no impact on services. Those in the latter camp cite two main reasons.

The first is that we have been here (or at least somewhere near here) before. Matthew Cooke, the then National Clinical Director for Urgent and Emergency Care, reviewed the A&E standards nearly ten years ago and proposed a basket of eight clinical quality indicators. These included measures of the time to initial assessment, time to treatment and total time in A&E. These measures are still being collected and published every month by NHS Digital (see Figure 8).

There are some differences between today’s proposals and the existing quality indicators. For example the time to treatment in the quality indicators is measured for all patients, while now it will be measured for patients with severe conditions such as sepsis. But frontline colleagues have still asked how much change will be possible if the conversation shifts from four hours to an average wait, but the total time in A&E remains the king of targets and disproportionately attracts the attention and focus of national bodies. The seductive simplicity, resonance and history of the four-hour target bedevilled the introduction of the clinical quality indicators, and it may yet bedevil the current proposed changes in the Clinical Standards Review.

Figure 8: NHS hospitals are consistently above recommended bed occupancy levels

_{Source: NHS England bed availability and occupancy data, and Winter daily sitreps 2018/19}

The second reason for scepticism was a more fundamental one. The rate-limiting factor for improving A&E performance is not how performance is measured, it is a combination of rising demand for services and constrained resources to cope with this demand. For example, hospital bed occupancy reached red-hot levels in NHS hospitals some time ago and has stayed firmly in the red zone ever since (Figure 8). And the unavailability of hospital beds has had a knock-on impact on how long patients wait in A&E before being admitted to hospital. Until the resources are in place to deliver sustainable and high-quality services, it is hard to see how changes to performance measurement will result in better care for patients.

Conclusion

So where does this all leave us? With more questions than answers, perhaps, and four final points to make.

First, it is right to review whether NHS targets are still fit for purpose. Clinical care and patterns of demand for services have evolved in the decades since these targets were first rolled out, and it is sensible to pause and consider if they are still working as well as possible to improve patient care. The NHS has just had a winter in which A&E performance reached historic lows, but this barely cracked the headlines in comparison to previous years. So, NHS England deserves credit for being willing to open this Pandora’s box of controversy by reviewing these key targets.

Second, some caution is needed. Making changes to these targets will not be straightforward and the implications for patient care are unclear. The concern must be whether the NHS will be given sufficient time to pilot these proposals and to fully engage patients, clinicians, managers and the public. The debate so far has been polarised and rushing through the next phase of the review does not intuitively feel like the best strategy for bringing parties together.

The pilots underway in fourteen NHS organisations will be key to establishing the evidence of what impact these proposed changes to A&E targets are having. This is particularly important as the new definitions of waiting times are more complex than simply being a promise of faster care – and hence are not ‘obviously’ better (nor obviously worse) than what is currently in place. But the proposed six-month piloting period is relatively short compared to the recent changes to ambulance standards that were trialled over an 18-month period through a process the then-Medical Director of NHS England described as ‘the most extensive ever conducted’. It is right that the transparency, robustness and design of these test sites should come under substantial scrutiny in the coming months.

Third, a reality check is needed on how much this review can achieve. With 100,000 vacancies in the NHS, unsustainably high hospital bed occupancy and breathtaking pressures on social care services, changing waiting time targets will not be enough to alter the fundamentals of how patients and the public experience NHS emergency care.

And finally, the scope of the review is arguably too narrow. The review is relatively silent on what happens to patients once they are admitted to hospital after going to A&E – which feels like a missed opportunity given the need for timely care in short-stay medical assessment units and medical wards in hospital. And the review’s focus on waiting times overall feels slightly regressive at a time when integrated care systems are attempting to transform how care is delivered. NHS England could do more to signal how they are thinking about measuring the performance of urgent and emergency care systems more broadly, including sharing the learning from the eight urgent and emergency care vanguards NHS England developed several years ago to look at these issues.

Ultimately, targets can act like an anchor in the NHS. This can be a good thing, and targets can stop our sense of ‘what good looks like’ from drifting further and further away from where it should be. But targets can also anchor us in a negative sense and lock us in to outdated ways of thinking about performance. Over the next few months, the pilot phase of the Clinical Standards Review will give the NHS the chance to think and discuss these issues for the first time in years.

In 1999 the NHS did not have A&E targets. But this did not mean A&E waits were not an issue for patients and the media, and the four-hour target was introduced precisely because long waits in A&E were a high-profile problem. Any new definition of waiting times must then be both clinically robust and a meaningful guarantee to the public that they will be able to access the services they need in an emergency. Otherwise the NHS may find itself in the invidious position of hitting a new target, while still missing the point.