People who arrive at A&E experiencing a mental health crisis will receive emergency care within one hour under NHS pilot schemes aimed at improving care and saving more lives.
The new standard, a significant step towards parity of esteem for mental health, is among a raft of proposed clinical improvements that aim to deliver rapid assessment and treatment for patients with the most serious conditions, and expand short waits for millions more NHS patients.
Patients experiencing a mental health crisis will also be able to access quick care in their own home or community, while no one who urgently needs help should wait more than 24 hours.
People with suspected cancer will receive a definitive diagnosis within 28 days of urgent referral by their GP or a screening service as part of the proposals, which will be field tested by the NHS.
Other new standards to be trialled include a rapid assessment measure for all patients arriving at A&E, coupled with faster life-saving treatment for those with the most critical conditions, such as heart attacks, sepsis, stroke and severe asthma attacks.
The proposals will support staff to focus on what matters most to the public and saves lives, including early assessment of everyone coming to A&E, the rapid start of treatment for those with the most serious illnesses and injuries.
A new measure of time in emergency department will also be tested, with the aim of ending hidden long waits and providing a more accurate view of hospital performance by recording how long every patient spends in A&E, not just whether their discharge or admission time breached the target.
This could prevent tens of thousands of unnecessary hospital admissions each year by improving upon the current four hour ‘cliff edge’ target.
Around a fifth of all emergency admissions from A&E happen in the final 10 minutes before the deadline, suggesting that hospitals are being driven to focus on the target, rather than what is the best approach for each patient.
In addition, the proposals will strengthen rules on reporting prolonged waits for those who need to be admitted to a ward, including reporting the most serious cases to the Care Quality Commission watchdog as a patient safety concern.
The use of average waiting times is based on the success of new ambulance standards, which have seen average waiting times for the most urgent calls improve by 14% over the last year, despite an increasing number of call-outs.
The proposals have been developed by some of the country’s leading clinicians, working with local health leaders and patient groups, to lock in the benefits of existing targets – some of which date back more than 20 years – while updating them to ensure they support frontline staff to deliver on the NHS Long Term Plan’s ambitions to save hundreds of thousands more lives.
Professor Stephen Powis, the NHS in England’s national medical director and leader of the review, said: “The NHS is aiming to improve care for patients and save hundreds of thousands more lives over the coming years, with greater access to mental health support, better treatment for the major killer conditions and services which are more joined-up, personalised and closer to home.
“So, as we build an NHS that is fit for the future, now is the right time to look again at the old targets which have such a big influence on how care is delivered, to make sure that they take account of the latest treatments and techniques, and support, not hinder, staff to deliver the kind of responsive, high-quality services that people want to see.”
Professor Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “The four hour A&E standard has been valuable in focussing efforts on improving emergency care but if we are to continue to improve patient safety and ensure every patient gets the priority they individually need it must be reformed and we must find better measures to ensure patient safety.
“Emergency departments need a set of standards which gives priority to patients with life-threatening conditions, ensures people get care in a timely way and puts pressure on the whole hospital to end long corridor waits for those who need admitting. We are confident that field testing these proposals is the safest and most effective way of improving care.”
Professor Carrie MacEwan, president of the Academy of Medical Royal Colleges, said: “We support any moves that improve the quality of care. If, as seems likely, the new standards on cancer, mental health, waiting times for both elective (referral to treatment times RTT) and in emergency care are demonstrably in the best interests of patients then we will support those. We look forward to working with NHS England and other stakeholders on a full evaluation of the pilot studies and any subsequent changes that are decided upon as a result.”
Detailed analysis is underway to build a full and accurate picture, but it is estimated that people go to their local A&E experiencing mental health problems up to a million times a year.
While not all will require an emergency response, the new 60-minute standard will be tested as part of the proposed overhaul of how hospitals are measured on the care they provide in emergency departments, and build on the progress made in recent years ensuring that psychiatric liaison services are available in major hospitals.
On cancer, pilots will focus on rapid diagnosis and treatment, with patients told whether they have the disease within 28 days of urgent referral from their GP or from a screening programme.
Other current cancer targets will be simplified into a 62-day total target for those with urgent symptoms to start treatment, and a 31-day maximum wait for all other types of cancer after a plan to treat has been agreed.
Reducing long waits for planned treatment such as cataract and hip operations will also be a priority, with a trial of an average measure for the start of treatment to tackle hidden waits, and reinforcing a six-week target for initial tests to take place.
Patient choice will also be reinforced, with hospitals expected to proactively support people who have waited for six months to find an alternative provider where they could be treated quicker, rather than the current system which places the onus on patients to ask for this to happen.
Staff bodies, patient groups and others will now be involved in the testing and development of the proposals, with evidence from the trials informing final recommendations.
Dr Nick Scriven, president of the Society for Acute Medicine (SAM), said: “Back in 2016, SAM made loud and clear calls for the NHS to stop aiming only to meet the four-hour standard when it was clear a whole system approach was required.
“The review of the target is an opportunity to focus on a range of patient outcomes and quality standards to measure pressures and take effective action earlier.”
The proposals draw on polling of more than 2,000 people conducted by watchdog Healthwatch England in January, which found that the vast majority thought it was very important to prioritise patients by urgency (79%) – more than double the number who placed the same importance on admitting or discharging people within a set time (38%). Three in every four (75%) of those who responded also said they thought it was very important that people should be assessed quickly when they arrive at A&E.
Previous analysis by Healthwatch England also showed that, when it comes to accessing routine treatment, significantly more people thought it was very important to be able to discuss all treatment options with NHS staff (66%) and that tests should be prioritised for those with the most urgent need (62%) than it is that everyone should be treated within a set target time (36%).
Healthwatch National Director Imelda Redmond said: “What shapes people’s experiences of A&E is often not how long they wait, but the quality of care they receive and how that care is delivered.
“People’s experience of care can therefore be significantly improved by staff carrying out quick initial assessments to reassure patients, prioritising those in greatest need and concentrating on communication to keep people updated on progress. This is of course what doctors and nurses working in A&E want to do all the time, but current targets sometimes draw attention away from this.
“When the four-hour target was introduced in 2004 it helped to significantly reduce the lengthy waits faced by many patients. But 15 years on the NHS faces different challenges, and from what people tell us it is clear that the time is right to look again at this core measure.
“Over the next few months Healthwatch will be supporting NHS England as they test new measures of waiting times in A&E to ensure they have a positive impact people’s experiences of care, as well as on clinical outcomes and patient safety.
“Ultimately we want to see targets free up hard working A&E departments so they can concentrate on delivering the best possible care for their patients.”
Rachel Power, Chief Executive of the Patients Association, said: “The findings from our recent survey on NHS waiting times suggests that, on balance, patients would be open to more sophisticated targets, including the possibility that people with less urgent needs may have to wait longer if that means the more seriously ill get faster treatment. Patient experience and outcome has to be at the heart of any changes, and it is essential that patients’ views are listened to and acted on through genuine consultation before any change to what the NHS provides, including to performance standards.”
Each of the proposals reflect advancements in clinical practice and how services are delivered over the years since previous standards were introduced, and are designed both to give patients more clarity and assurance about the things that matter most to them, as well as help frontline staff and local health leaders deliver on the ambitions to improve care and outcomes set out in the recent NHS Long Term Plan.
The clinically-led review of standards was announced by the Prime Minister in June 2018, at the same time as she announced additional investment over the next five years to support the NHS’s plans for improved care, which were set out in the NHS Long Term Plan in January.
Since the Prime Minister made her request, Prof Powis has been working with leading national medical bodies, Healthwatch England, local hospital leaders and others on identifying and solving shortcomings in the current NHS target regime, which has developed over the last 20 years.
The review has focussed on determining what matters most to patients, on the clinical issues with the current target regime, and what NHS staff believe will help them provide the best quality care for patients.
The proposals, detailed in full in an interim report by Professor Powis published today, will be trialled in a number of areas across England in the coming months. Evidence from the test sites will be evaluated and used to inform final recommendations later in the year.
The test areas will be published shortly, along with details of how the impact of the proposed new standards will be measured to ensure that they:
- promote safety and outcomes;
- drive improvements in patient experience;
- are clinically meaningful, accurate and practically achievable;
- ensure the sickest and most urgent patients are given priority;
- ensure patients get the right service in the right place;
- are simple and easy to understand for patients and the public; and
- do not worsen inequalities.
2019/20 will therefore be a transition year between old targets and the updated standards which, following the results of field testing and consultation, will begin to be implemented across the NHS from April 2020.
The trials are backed by wide cross-section of medical leaders, patient groups and charities.
Paul Farmer, Chief Executive of mental health charity Mind, said: “People now expect that the NHS will help someone with mental health problems with the same timeliness as for their physical health. We know that too often, people with mental health problems find that isn’t the case.
“The Long Term Plan is an opportunity for people with mental health problems to get the support they need, when they need it. That’s why we are pleased to see tangible improvements now being proposed, including making sure people who end up in A&E in a mental health emergency receive care within one hour.
“This target, along with better care in the community, could help people avoid reaching crisis and offer them quick support when they do. Treating people in their own homes or providing sanctuaries, safe havens and crisis cafes should mean more people are able to receive help without needing to go to a clinical setting.
“People with mental health problems deserve to be treated with respect and dignity and to have their views properly taken into account, so we also welcome changes that will give people greater choice and control in their treatment.
“More joined up care across the NHS should make it easier for people with mental health problems to get help early on. As pilots are rolled out, the proof of delivery of these proposals will be in the experiences of people trying to access the services they need. With so many people needing support for their mental health, it’s never been more important to get this right.”
Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: “We know from many years of experience that, when implemented correctly, targets can be beneficial for the care patients receive from the NHS.
“To ensure that all targets are realistic and in the best interests of patient care at that time, it is sensible that they are regularly reviewed, and where appropriate, that alternatives are explored, tested and thoroughly evaluated to ensure that the care patients receive is always improving – to this end we support the course of action NHS England is taking, and we are pleased that the proposals will be piloted and evaluated before wider roll-out.”
Dr Ron Daniels, CEO of the UK Sepsis Trust, said: “The UK Sepsis Trust welcome this initiative, at a time where incidences of sepsis show no sign of slowing.
“Without timely diagnosis and treatment, sepsis can result in organ failure and death in a matter of hours; with every hour before the right antibiotics are administered, risk of death increases.
“This initiative, successfully implemented, will ensure that the right care will be given to those who are in most urgent need of it. It has the potential to save thousands of lives every year and it’s fantastic that NHS England continue to test new standards of care and strive to improve patient care and treatment across England.”
Niall Dickson CBE, Chief Executive of the NHS Confederation, which represents organisations across the health sector, said: “Targets matter – they can concentrate minds and have helped provide faster access to care for millions of patients. They helped eliminate long waits in the 2000s when patients were waiting up to two years for inpatient treatment and up to 12 hours in A&E. This had to change and, backed by more staff, funding and focus, the NHS achieved great things for patients. But targets are blunt tools, and some need to be refined in an era where patients have more complex needs.
“This package of reforms is needed – it should help front-line staff focus on caring for the patients with the most critical needs. And it will help reduce some of the challenges we see now – for example in A&E staff are under enormous pressure to admit patients just ahead of the four-hour limit even when this is not necessarily the clinical priority at that moment.
“This is a more nuanced approach, but we must not lose sight of the importance of making sure patients have fast access to care. What matters is that changes are based on sound evidence on their impact on patients and staff. That is why we welcome the plan to pilot these changes in some areas and test their impact before any final decisions are made to roll them out across the NHS.”
Sara Hiom, Cancer Research UK’s director of early diagnosis, said: “We know that the time from being referred for tests to a cancer yes/ no diagnosis is an incredibly anxious one for patients and their loved ones, so it’s encouraging to see careful consideration being given to the new 28 day Faster Diagnosis Standard.
“Cancer Waiting Times are helpful in setting clear expectations for patients, but growing evidence shows that the current standards don’t work in all situations and meeting the 62 day target does not always lead to a better chance of survival or improved patient care. Cancer Research UK therefore welcomes this commitment to now fully consult the cancer community to make sure that the amended standards are fit for purpose and clinically meaningful.
“It will also be critical that enough of the right staff with the correct kit are available to deliver these standards against the ever growing demands on our health system.”
Simon Gillespie, chief executive of the British Heart Foundation said: “When someone has a heart attack or stroke, rapid access to the most effective treatment is critical, as delays can result in lifelong disability or death.
“The trialling of much-needed improvements that could cut waiting times are a welcome development which could help people with heart and circulatory diseases get the prompt care they need. In the long term, improving access to faster treatment for heart attack and stroke is likely to improve survival rates, which is a key aim in NHS England’s Long Term Plan.”
Professor Wendy Burn, president of the Royal College of Psychiatrists, said: “We welcome these new targets and the focus they will bring to helping improve mental health services.
“We support the proposal to pilot these targets to make sure they are working as intended. We believe the targets will help attract more funding into mental health care, which can only be a good thing after decades of underinvestment.
“But to meet them, we need the workforce to do so. This must remain a priority.”
Juliet Bouverie, Chief Executive of the Stroke Association, said: “When stroke strikes, part of your brain shuts down. And so does a part of you. The impact varies depending on which part of the brain is affected. The new rapid care measures are good news for stroke patients. The faster a patient receives appropriate treatment on a specialist stroke unit, the more likely they will survive and make the best possible recovery reducing the impact of this devastating condition on people and society.
“We are working with NHS England to make improvements to stroke treatment which will help ensure that these and other new standards for stroke care are met.”
Anthony Marsh, Chair of the Association of Ambulance Chief Executives, said: “Updating ambulance response standards has allowed paramedics and other ambulance staff to prioritise those patients in greatest need, while ensuring that every call counts, providing a real incentive to tackle long waits – the things that matter most to patients, the public and our staff.
“Over the last year, average response times have improved considerably despite the number of 999 calls continuing to rise, with more than a minute shaved off the average response to life and death calls.”
Martin Berry, Trustee, College of Paramedics said: “Many of the targets relating to emergency care are 20 years old and increasingly do not reflect the evolving nature of how we care for patients. With an ever-growing emphasis on measuring quality of outcomes, rather than simplistic arbitrary time targets, it is right that they are reviewed.
“Paramedics continue to provide quality care within the community, and increasingly in non-traditional settings, providing multidisciplinary care to those who are in need. The College of Paramedics welcomes open dialogue and collaboration that drives for delivering the right care, by the right person, at the right time.”
Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said: “Today’s announcement around pilot schemes focusing on speeding up responses for cancer, mental health and other urgent health needs is a very important step forward.
“It is crucial that help is available at the earliest possible stage, for both physical and mental health issues, if we are to prevent issues escalating. For example, perinatal mental illness affects up to 20% of women. If left untreated, it can have a significant and long lasting impact on a woman and her family.”
Lynda Thomas, Macmillan Cancer Support’s Chief Executive, said: “Everyone with cancer deserves to receive a diagnosis and to start treatment as quickly as possible, and patients tell us that delays in the process can increase their worries at an already anxious time.
“The most important thing will always be that we get the standards right for patients, so we will be looking carefully at these proposals and welcome an opportunity to work with NHS England during this trial to evaluate the impact it has on improving the experience for people with cancer.”
President of the Royal College of Pathologists, Professor Jo Martin, said: “We welcome the refreshed clinical standards and the focus on review. We want everyone to have timely access to the diagnosis and care they need. No one should be left worrying longer than is absolutely necessary to get a diagnosis and treatment.
“Our pathologists are key to most of these standards. We are continuing to work hard to make sure we have the right staff and IT infrastructure to make delivery possible.”