Improvement in four-hour performance in latest RCEM Winter Flow data calls into question the need to scrap the target

Posted On: 
1st March 2019

Responding to data from the College’s Winter Flow Project for the week ending 24 February 2019 showing average four-hour performance at over 50 emergency departments at 79.01% – up from 76.87% the previous week.

Gordon Miles, RCEM Chief Executive, said: “It is ironic that – if The Times newspaper is to believed – the Government has chosen the very day in which the Winter Flow Project records the biggest weekly improvement four-hour performance this year (2019) to announce that they intend to scrap the four-hour standard for emergency departments.

“In the four years that the Winter Flow Project has been in operation we have seen a steady, if not entirely uniform, decline in four-hour standard performance. By way of illustration, at this point in 2015-16 four-hour standard performance stood at 83.93%. But as we have argued consistently, this is not the fault of the patients, the staff that work within Emergency Departments or the hospitals that employ them. This is the result of a systematic under resourcing of the secondary care sector and a lack of acute beds which had meant it has been unable to keep pace with changes to both the level and complexity of patient demand.

“However, this should not be taken to mean that the four-hour standard is without value, or that it is not in the interest of those same patients who our Emergency Departments are there to treat. Previously changes to performance thresholds have led to near immediate and sustained deteriorations in performance and both patients and staff have had to deal with the consequences.

“In 2014 the Royal College of Emergency Medicine concluded that:

“Before the introduction of the four-hour standard, resources available to A&Es were grossly inadequate. This standard protects all A&E patients.”

“That statement is as true today as it was five years ago. The Government appears to be proposing a target which will only apply to those most vulnerable patients who require admission. The rationale for this being that these most vulnerable patients should be prioritised and that they are not being prioritised at the moment. As we have stated repeatedly, this is not the case, the most vulnerable patients are always prioritised, and it is a mathematical certainty that removing large numbers of lower acuity patients from this or similar performance measure(s) will make any time-based target harder to hit.  We also have concerns for those patients whose conditions are not easy to diagnose and how they will be looked after in these plans.

“It is also worth stating that the way the Government has resourced the system has made hitting the target more difficult in a number of different ways. The idea that insufficient acute beds leads to vulnerable patients facing long waits languishing in corridors is easy to grasp and conceptually straightforward. This has been labelled the ‘Exit Block’ theory and even the NHS’s own Strategy Unit has recently acknowledged its validity. 

“What is less obvious, as the NHS Strategy Unit also highlighted only a few days ago, is that as bed pressures and admissions thresholds have increased, clinical practice has changed in a way that means we now spend more time testing patients who might otherwise have been admitted, in an effort to keep them out of the hospital. What this means is that waiting times have increased as a result.

“Whilst we are open to discussing the clinical quality indicators that could be developed to enhance the treatment of patients, it remains our view that the real solution to these problems is to properly resource the system so that these targets can be achieved. In that way we can ensure the highest standard of care for the patients that our NHS exists to serve.”