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Jeremy Hunt's two-tier targets could deepen A&E crisis

Caron Heyes
16/01/2017

Responding to warnings from the Royal College of Emergency Medicine that overcrowded and understaffed A&E departments are putting people's lives at risk, Health Secretary Jeremy Hunt offered the excuse that Tuesday 27 December last year was the busiest day in the NHS’s 69-year history.

I'm sure this is true, as is his comment that cold weather forecast this week will only add to the pressure on A&E departments stretched to breaking point.

But Mr Hunt's comments – including that too many people use A&E unnecessarily – offer little comfort to people who will face medical emergencies they don't even know about yet.

Mr Hunt's answer to the deeply worrying situation facing all of us is to focus on targets and, specifically, ending the commitment to patients of a 4-hour treatment standard, announced in 2000.

To protect that standard, Mr Hunt said minor health problems should not be included in the 4-hour target, only urgent problems.

Intrigued by this suggestion, I asked an A&E Consultant if this would relieve some of the burden on his A&E Department. He felt that such a measure could actually increase the risk of delays, causing avoidable injury to patients.  

It sounds like a simple solution, but fails to address the fundamental problem of why more patients are resorting to A&E rather than seeing their GP, and the practical  difficulties of determining which patients fall into what category – urgent or minor.

To determine whether a patient needs urgent treatment, nurses perform an initial assessment (triage), after which the patient goes into a queue to see a doctor.  However, not all problems can be identified accurately at triage and may need further investigations and examinations by a doctor to reveal a serious problem needing urgent treatment.  Making a decision at triage that a patient does not need urgent treatment runs the risk of overlooking a problem that needs treating as soon as possible.  

If decisions are made in triage that a patient's problem is not urgent and they develop a serious injury that could have been avoided by earlier treatment, that decision could be negligent. For example, a patient goes into A&E complaining of two episodes over the previous three days of bilateral arm pain, heavy sweating and being flushed.  They also describe some chest pain. 

This patient is a clear candidate for acute coronary syndrome and the appropriate treatment is probably to admit them, run some tests, confirm if indeed they are at risk of heart failure and treat them accordingly.  Patient 2 might present with similar symptoms, but without the chest pain. His symptoms are not obviously of heart problems and patient 2 will be dismissed with non-urgent problems, such as flu. According to Mr Hunt's recommendations, patient 2 does not take priority in seeing a doctor, but while waiting his turn, has a heart attack.

To operate a two-tier A&E system, how do you decide if someone falls in or out of the 4-hour standard?  Do you say obvious urgent cases are seen within 4 hours, plus patients with an unclear diagnosis, but all other patients, including those who appear to have a minor ailment such as stomach ache or headache, are only treated when someone becomes free? 

This virtually impossible question puts doctors in conflict with their duty of care to do their best by their patients. 

Patients go into A&E because they are feeling unwell. Some will present with obvious life threatening conditions and are often brought in by ambulance.  They will always be treated as an emergency, irrespective of targets.

However, there is a very valid argument that if you create 2 tiers of time in which to treat patients, mistakes will be made.  Rather than throwing some outside the 4-hour target, more helpful could be broader targets that allow clinicians time to exercise their judgement and decide which patients take priority and which can safely wait a little longer.