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NHS: Accident and Emergency Departments

Volume 795: debated on Tuesday 5 February 2019


Asked by

To ask Her Majesty’s Government what is their response to the assessment of the President of the Royal College of Emergency Medicine that removing the four-hour accident and emergency treatment target would have a “near-catastrophic impact” on patient safety in many emergency departments.

My Lords, I note the concerns of the Royal College of Emergency Medicine and assure it, and the House, that patient safety remains paramount in any NHS care setting. As I mentioned in the excellent debate that the noble Lord, Lord Hunt, introduced last week, the NHS long-term plan will reform urgent and emergency care, and NHS England’s clinical review of standards will report its interim findings in spring 2019. Until then, we are clear that existing core access standards will remain in place.

My Lords, I am grateful to the Minister. She will know that, before the four-hour target was introduced, we had dangerously overcrowded A&E departments, very long waiting times and unsafe care generally. It is clear from the evidence that the chief executive of the NHS recently gave to a parliamentary committee that he wants the clinical standards review to get rid of the four-hour target under the guise of giving greater priority to the most urgent treatments. The problem with that is that most urgent treatments get priority already. There is a real risk that, if you let the four-hour target go, many patients will have to wait longer and longer. The royal college is concerned about patient safety. Is the answer not to invest in more beds and adult social care for frail, older patients and then get a more effective flow of patients through hospitals? In that way, the target could be met.

My Lords, the noble Lord is absolutely right: performance targets are important. However, we must ensure that the NHS is focusing on clinically appropriate targets. The clinical review of standards is considering standards for both physical and mental health. Following its interim findings, any recommended changes will be carefully field-tested across the NHS before they are implemented. An impact assessment will be published and changes to the NHS constitution will be consulted on, as is legally required.

My Lords, I remind the Minister that 12 years ago, when I was the ministerial enforcer of the four-hour A&E target, the royal college came to plead with me not to abandon it. Its arguments were not only the ones made by the noble Lord, Lord Hunt, but that this target had caused acute hospitals to reorganise their affairs much more efficiently. How will getting rid of the four-hour target impact on the Government’s drive to improve the efficiency of the NHS?

My Lords, I have already said that performance targets are important. The Academy of Medical Royal Colleges released a statement on 30 January, which said:

“Reviewing, updating and improving the clinical standards to ensure that they remain relevant and appropriate is sensible and overdue. We support an evidence based review that is driven by clinical considerations as to what is appropriate, that informs and promotes changes in service delivery where needed and involves wide input from all relevant parties … any review may suggest change or reinforce current measures”.

I could not have put it better myself.

My Lords, the acid test for any waiting-time targets is the clinical outcomes they deliver. In 2017, NHS England recommended—and the department subsequently accepted—reforms to the ambulance waiting-time targets, but that took place only after a two-year clinical trial and an independent assessment by the University of Sheffield of the impact on patients of all kinds of severity. I suggest that, if there is to be movement in this area, it should proceed cautiously and only after following a similarly robust and objective process.

My Lords, of course I entirely agree with my noble friend. As I have said, there will be robust evaluation, monitoring and assessment before any targets are put in place.

My Lords, there is no doubt that emergency departments are currently working at full tilt to care for their patients. I recently visited one that had totally reconfigured its workspace. By so doing, it had been able to operate much more efficiently, saving precious time. I believe that it had received grant funding to do this. How many emergency departments have done the same, with or without a grant?

My Lords, forgive me, I do not know the answer in relation to grants and will have to write to the noble Baroness, but she is right that NHS A&E admissions have been quite significant. Demand has increased. To put this into context, the NHS addressed just under 2,500 more attendances per day on average within the four-hour standard in 2017-18 compared with 2009-10, and 86.4% of patients admitted were transferred or discharged within four hours. Performance has improved since last year but we recognise that we have not hit the standard.

My Lords, is not the simple Answer to this Question that we need more nurses and doctors in our accident and emergency units? The real problem is that there are simply not enough there. I do not know when the Minister was last in an accident and emergency unit, but over the past 18 months or so I have been to three different hospitals six times and waited for hours with somebody who was extraordinarily ill and might well have suffered the ultimate consequence of his illness. It is simply not good enough to answer my noble friend’s Question in the way the Minister has done. This is a real issue and people are in great difficulty because we simply do not have enough nurses and doctors.

My Lords, I am very sorry to hear of the noble Baroness’s experience of A&E. Just to reassure her, I went to an A&E department not very long ago, so I know and understand the pressures on A&E departments. Indeed, I have worked in A&E departments, so I understand the pressures on staff too. I reassure her that we are doing everything we can to ensure that there are more nurses, doctors and consultants working in A&E. I do not have the figures at hand, but we have more NHS consultants working in A&E than we have ever had.