Derek Bell: Four-hour target in A&E must be maintained

The current four-hour standards across the UK were introduced due to patient pressure. Picture: John Devlin

The current four-hour standards across the UK were introduced due to patient pressure. Picture: John Devlin

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The suggestion this week by Health Secretary Jeremy Hunt that the four-hour target for accessing emergency care be reconsidered is concerning, and could have the unintended consequence of creating ‘second class’ patients.

As a College with members working in hospitals across the UK, we believe that Mr Hunt’s suggestion that the target should not apply to those with more minor health problems is not the correct way to tackle the problems faced by accident and emergency departments around the country.

The current four-hour standards across the UK were introduced due to patient pressure, and supported by Royal Colleges. The access to treatment target is an important measure of the whole system response to care, covering the entire patient journey when they are in need of urgent healthcare.

When both Westminster and the Scottish government watered down the target to apply to 95 per cent of patients rather than 98 per cent, performance fell.

Not measuring those patients ‘perceived to have less significant illness’ will not remove them from the system. It may actually make it harder for those who may have difficulty making their voices heard – for example, the elderly, the vulnerable and those with mental health problems. There may also be those who are sicker than they appear.

We are increasingly seeing pictures of patients lying on trolleys waiting for beds to become available and experiencing long waits in A&E — this will not be addressed by Mr Hunt’s suggested changes. Overcrowding may simply move to other parts of the hospital such as waiting areas.

One of the important ways of meeting the four-hour target is addressing capacity and patient flow throughout the hospital. The College has been working in partnership with the Helen Hamlyn Centre for Design at the Royal College of Art, to consider how design solutions can be applied to these issues. This has resulted in the development of several digital and analogue design solutions visualising the patient journey, which we hope will benefit our colleagues across the UK.

It is clear that the pressures, both in elective and acute and emergency medical care, are similar throughout the UK however the approaches taken by the devolved health systems are increasingly divergent.

While we cannot be complacent, emergency departments in Scotland have consistently performed better than other parts of the UK over the last 18 months. And while they are also experiencing the same winter pressures, including recent difficulties meeting the four-hour target, Scotland is somewhat more resilient than England and will recover from these pressures more quickly. This is in part due to the National Programme, ‘Six Essential Actions to Improving Unscheduled Care’, which shares best practice, and appears to be showing patient benefit.

Our sister College in London has this week called for more funding for the NHS. While this, of course, would be welcomed we need to look at the problems and identify solutions that can have an impact both in the short and long term. The NHS in England should consider introducing a similar National Programme if it wants to fix this problem – not simply changing the way the waiting time target is measured.

Professor Derek Bell is President of the Royal College of Physicians of Edinburgh

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