Goodbye four-hour target?

Published: 24 August 2010

RCN Acute Care Adviser Alan Dobson provides an overview on plans for the four-hour waiting standard and seeks your views on its proposed abolishment…

Background

The Secretary of State for Health the Right Honourable Andrew Lansley CBE MP has announced his intention to abolish the four-hour standard with effect from April 2011. In the interim, the 98% target has been relaxed to 95% in an attempt to ease the pressure on clinicians and managers alike.

Despite this initiative, widespread reports from around the country indicate that 98% remains, largely due to existing contractual arrangements between the acute trusts and the primary care trusts (PCTs). If this means that the infrastructure, support and investment designed to deliver 98% remains in place, this will benefit all parties by allowing the 95% to be achieved. If, however, this means that infrastructure is being withdrawn from emergency departments and elsewhere, then clearly this is against the spirit and intention of the change. The College of Emergency Medicine (CEM) and the RCN would welcome further information regarding such situations.

Proposal

The Secretary of State’s intention is to replace the four-hour waiting standard with a basket of measures designed to more accurately reflect quality of care and outcomes. The CEM and RCN have been invited to work with the Department of Health in developing these measures.  This provides a unique opportunity for clinicians to help to define the measures by which emergency care will be assessed in years to come.

Concerns

There have been concerns expressed that abolition of the four-hour waiting standard will result in a significant loss of focus on emergency care in general and on emergency departments in particular, with major implications for workforce planning and other developments that are still urgently required.

The view of the CEM and the RCN is that carefully constructed measures will optimise the quality and standard of care provided for our patients, enhance the position of emergency care within the health system and allow the key issues – for example, that of emergency medicine consultant numbers – to be acknowledged as an essential component of developing a comprehensive and consistent programme of the 24/7 emergency care uniquely provided in emergency departments.

Latest draft of measures

National Clinical Director for Emergency Care, Professor Matthew Cooke, has developed the initial draft of measures in conjunction with a core group from the CEM and the RCN. The latest draft of these measures is attached for your information and comment.

Key points

• Time measures remain integral to this new initiative
• The Secretary of State has signalled that the focus should be on outcomes, not processes, and further work will be undertaken in the next few years to develop more robust measures. Particularly, there is a need to define how best to bring out the link between high-quality clinical practice and patient outcomes more explicitly without resorting to the use of process measures
• Patients and staff experience is central to this initiative
• This is not the final set of measures. The intention is that the measures will be reviewed annually to allow refinement. However, it should be accepted that this initial draft is likely to form the core set that will inform the strategy for the delivery of emergency care, particularly in the context of the implications of the recently published white paper
• There are an infinite number of possible measures that could be included, of course. The principles of the measures that will form this group will include:
  i) already measured
  ii) no new industry is generated in collecting these measures
  iii) current IT (although variable in the extreme) will allow the measures to be collected without hindering clinical care
  iv) however carefully phrased, all suggestions will potentially be subject to gaining or manipulation by those who so chose.

Conclusion

In conclusion, this represents a significant opportunity for nurses involved in emergency care to contribute to the development of a set of measures that will drive emergency care strategy at the DH, the acute trusts and in the forthcoming new commissioning process.

We need your feedback…

If you have any comments, suggestions or feedback, please visit the RCN’s ECA Discussion Zone online and enter the debate, or contact ECA Chair James Bethel on email: James.bethel@wlv.ac.uk.

Our impression is that the Secretary of State is keen to canvas expert clinical opinion, so I look forward to your support.