Waits for emergency care are worst for 10 years, figures show

Dear Sir

It appears that every winter the NHS has a crisis with increasing attendances to A&E departments and hospitals unable to cope with the flow of patients. Numerous measures have been suggested and implemented but there seems to be little respite. The Royal College of Physicians has produced an acute care tool kit emphasising the role of ambulatory care in helping hospitals cope with increased number of patients[1] Several hospital trusts have created well equipped ambulatory care units and have been recognised for their commendable efforts[2] It is however disheartening to note that these trusts have also had difficulty coping with the current NHS pressures.

The BBC have created an A&E tracker which helps the public keep abreast with the performance of their local trusts[3] In addition to the 4hr target performance, the tracker also gives information on numbers of admissions, operations cancelled, beds lost due to Norovirus infection, delayed transfer of care etc. It is worth noting that the only 2 trusts that are not exclusively children's services that have been able to not breach the 4 hour target differ from other trusts in their performance on delayed transfer of care. Both Luton & Dunstable hospital and Homerton Hospital have reported data showing that their delayed transfer of care patients are well below the national average for several weeks. If these figures are accurate then it would appear that the BBC have been able to give us the most effective solution to the current crisis.

Should we not be accepting that there will be an increase in number of patients visiting hospitals but we could cope with the numbers if we have effective measures to reduce the delayed transfer of care patients?

References:
1. https://www.rcplondon.ac.uk/resources/acute-care-toolkit-10-ambulatory-e...
2. V. Connely, D. Thompson: All in a day's work: the drive for better ambulatory care. Health Service Journal May 2014
3. http://www.bbc.co.uk/news/health-25055444

A small increase in the proportion of A&E waits which are greater than 4 hours long says nothing about the mean or median waiting time. The statistics presented cannot even rule out a decrease in the average waiting time, which would contravene the assertion that "waits" (in general) are worsening.

Hence "waits for emergency care are worst for 10 years, figures show" is not a true reflection of the content of the article.

Dear Editors

It has always vexed me that there is no actual evidence presented at the time of the grand annoucement of the new NHS by the New Labour government in 2000, on what basis the target goal of 4 hour ED waiting time, was chosen; it is even more laughable that their grand plan expected to achieve 100% compliance within 4 years (by 2004) (1).

To me the 4 hour target was always a marketing construct, in which no one have proven that 3 hours, 5 hours or even 6 hours target makes any difference

As various UK lobby groups are fussing over the "92.6%" performance of the 4-hour-target, as the lowest performance in 10 years, the same national performance would have been the envy for many centres in OECD countries including Australia.

When is 92.6% performance not good enough?

Especially when there is no good evidence that a better performance leads to improved outcomes consistently across the NHS? (2)

The attempt for to transplant a construct in the mind set of a commercial service industry had failed miserably in spite of massive injection of health funding, system overhaul and manpower re-deployment.

This is keeping in mind that in most (if not all) situation, the emergency department commands priority access to radiology and pathology services, nurse to (in departmental bed) patient ratio matching or better than the regular medical ward, almost certainly better doctor to (in dept bed) patient ratio compared to regular medical ward.

Furthermore, the basis of the 4 hour target reaches across all triage categories. While I do not discount the need to assess and treat patient with higher triage catergory (conditions which requiring immediate or urgent attention to preserve life or limb), surely conditions with no immediate threat to wellbeing of the patient can afford to wait longer than 4 hours, if services are overwhelmed or tied up by sicker patients at the time of the day. Patients with lower triage category do include those who may still need admission for inpatient care, but their outcome may not been any different if they arrive into a "regular" medical ward any time later than the 4 hour target.

Bear in mind that the 4 hour target includes assessment, investigation, treatment and physical transfer to a regular ward if admitted, or discharged to hom within the time frame, and for all comers.

I still find it amazing that some still propagate ideas that access block (in emergency department) contributes directly to higher mortality of admitted patients, inspite of highly skilled medical and nursing staff and monitoring devices physically available in the department as in contrast to the regular ward.

I beg to differ: access block is symptomatic of an overcrowded hospital, and it is hospital overcrowding that kills, not just the idea that it takes more than 4 hours for a patient to physically reach a regular ward bed from the time of presentation.

It is time we reexamine at the concept of using 4 hour as a goal, and address hospital overcrowding, rather than only emergency department access block.

References

1) Department of Health. The NHS Plan: a plan for investment, a plan
for reform. Londres: Deparment of Health; 2000.

2) Jones P, Schimanski K. The four hour target to reduce emergency department 'waiting time': a systematic review of clinical outcomes. Emergency Medicine Australasia 2010; 22(5): 391-398