The Committee has asked the Scottish Government to consider whether the 98% standard is appropriate and achievable given comments that some patients may need to wait in A and E longer than four hours for clinical reasons.
The 4 hour target of 98% of visits became the standard set by the Scottish Government in 2008. In April 2013, an interim target of 95% was set for delivery by September 2014. Earlier this year, a report from the Auditor General Scotland (AGS) showed that a number of NHS boards would find it difficult to meet the Scottish Government interim target of 95% set and in November, data was published showing that NHS performance for the year to September 2014 was 93.4%, the same as when the target was first introduced.
Within the report, the Committee welcomes the additional funding to support Boards, to respond to the deterioration in A&E performance, from the Scottish Government of £27 million provided over three years from February 2013.
Public Audit Committee Convener Hugh Henry MSP said:
“To have 5 of the 14 health boards failing to meet the interim 95% target on time is disappointing to say the least, especially when only 3 NHS boards are meeting the 98% standard set by the Scottish Government. However, there is always a clinical need to balance speed of care with quality of care and we agree with the AGS that waiting times for an A&E department can be an important indicator of pressure on the health system as a whole. Against this backdrop, and with the majority of boards failing to meet the set standard, we question whether that standard remains reasonable or achievable.”
The Committee report outlines that a step change in activity and service redesign by NHS health boards will be necessary to meet the A&E waiting time standard of 98% and highlights the importance of:
- Accurate and robust data on all the sources of referrals to A&E departments.
- NHS boards understanding the impact different sources of referrals have on A&E attendances. This is the starting point for trying to manage people who inappropriately attend A&E departments and could be treated in or redirected to other parts of the health service if these services were available at the time. This in turn could help patients make different choices.
- Work by the Scottish Government on what NHS boards are doing to ensure that sufficient capacity exists in other parts of the health service to support those patients who could be redirected away from A&E.
- Scottish Government supporting improvements in patient flow through A&E including how it is supporting hospitals to move away from the standard practice of week day working in some parts of the hospital service. The Committee has also sought clarification from the Scottish Government on how it proposes to better understand the reasons why self-referral patients attend A&E and support early input from experienced medical staff.
Committee Convener Hugh Henry MSP continued:
“At this time of year in particular, A&E departments need to be able to focus on what they are there for – accidents and emergencies. NHS boards need to better understand why people are coming to A&E, when patients could be redirected to other areas of the health service and treated just as effectively. Some boards are doing great work in this area and we know the Scottish Government is supporting this. However, whether other services are available when they are needed, and whether people know enough about the alternatives to attending A&E needs to be examined further. We have called on the Scottish Government to take action to increase understanding in this area and improve the robustness of data collection. Only in understanding the problem can more appropriate action be taken to address it.”
Within the report, the Committee also comments on recruitment and retention within A&E departments and calls for:
- Clarification from the Scottish Government on how the Greenaway review implementation will improve the recruitment and retention of postgraduate medical trainees in A&E.
- Information from the Scottish Government on the extent to which it considers the national contract adequately recognises the changing working conditions of consultants, particularly those in A&E, and supports service redesign by enabling innovative working practices to be adequately rewarded.
In Scotland there are 31 A&E departments which provide essential services within the NHS, typically assessing and treating patients with serious or life-threatening injuries or illnesses. The AGS reported that around 1.35 million patients attended these departments in 2012/13 at a cost of £163 million. There are also 64 minor injury units (MIU) in Scotland that provide treatment to 266,439 patients a year at a cost of £25 million.
In 2004 the Scottish Executive established a target that, by the end of 2007, 98% of A&E patients should wait no longer than four hours from arrival to admission, transfer or discharge. This applied to A&E as well as MIU. In March 2008 this target became a standard to treat and discharge or admit 98% of patients within four hours of arriving at A&E. In the quarter ending March 2010, 96% (365,949) of patients were seen within four hours compared with 88% (334,907) in quarter ending June 2006.
The AGS reported that since Audit Scotland's last report in 2010 (entitled Emergency departments) performance against the 98% standard fell from 97.2% in December 2009 to 93.5% in December 2013, although there was an improvement during 2013. In evidence the Scottish Government observed that “the figure of 94% has been quoted for the published data to June 2014.”
The AGS reported that due to the variation in services that are provided in A&E departments across the country, there is no single factor explaining the deterioration in waiting time performance since 2008/09. The following can affect waiting time performance—
- pressure on the availability of hospital beds from an increasing number of patients being admitted as emergencies and delays in patients being discharged from hospital
- increasing complexity of care
- local policies on emergency admissions
- local policies on informing A&E patients about alternative services
- the time of day that patients are discharged from wards
- staffing pressures.
The Committee also heard evidence that waiting times performance can be affected the availability of home care and care home places, in some areas, which can delay the discharge of patients from hospital whilst they wait for appropriate care outside the hospital. In addition the AGS reported that overall demand for A&E and Major Injury Units (MIU) had increased from 1.57 million attendances in 2008/09 to 1.62 million in 2012/13.
In April 2013, the Scottish Government introduced a new interim target of 95% of patients being treated within four hours by the year ending September 2014.
At the time of the Committee taking evidence (in October 2014) on the A&E report, the Scottish Government was unable to advise whether it would be able to hit this target as the figures for September 2014 would not be released until November 2014. The AGS, however, reported that a number of boards would find it hard to meet the 95% interim target by September 2014.
On 25 November 2014, Information Services Division (ISD) Scotland reported that NHS in Scotland performance against the 95% interim target for the year to September 2014 was 93.4%, the same as that at the 95% interim target start date in April 2013. Of the 14 NHS boards, ISD Scotland reported that 9 boards met the target milestone of 95% (NHS Borders, NHS Dumfries and Galloway, NHS Fife, NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles).
The Greenaway Review refers to: Securing the future of excellent patient care - final report of the independent review led by Professor David Greenaway can be accessed via this link http://goo.gl/9TO6UB