I was wondering whether you had seen the letter below from HQ.



Has anyone acheived the 98% target (without cheating). Our own performance
used to be around 95% but last year we were heading in the opposite
direction to the new National Target......... we had a further increase in
New Patient numbers.



Unless A&E can target our resources to A&E patients and stream GP patients
back into the community I think there will be some unhappy people in the
Department of Health.



Any thoughts?



Ray McGlone

A&E Lancaster







To: SHA Chief Executives



Gateway Number 2504





17 December 2003





A&E FOUR HOUR TOTAL TIME TARGET: EXCEPTIONS & PERFORMANCE RATINGS


The NHS Plan states that by December 2004 all A&E patients should be
discharged, admitted or transferred within four hours of arrival. This
letter sets out our thinking on how that target should be applied in
patients' best interests.



The first thing to stress is that raising A&E performance is central to our
plans for the NHS. The improvement during 2003 was a real and remarkable
achievement but it took us only part of the way there - performance now
needs to start climbing again, and sharply. The target can only be refined
to the extent that it works in patients' interests and reflects truly
exceptional circumstances, and the standard we are aiming for has to remain
at 100% against the four hour target.



We also need to listen when clinicians warn us that a target could adversely
affect some patients' care. To that end we recently completed a consultation
exercise on defining the circumstances in which patients might need to spend
longer than four hours in an A&E department, and we have now reached a
consensus with the BAEM and the RCN.



We don't intend to routinely monitor individual clinical exceptions. Instead
we want a system that lets local staff manage their service while giving
patients the reassurance they need. It has therefore been agreed that, after
allowing for all exceptional circumstances, recorded performance should stay
above 98% from 1 January 2005. 98% from this point will be the minimum
Operational Standard for emergency care.



There are a number of important points about this to bear in mind:



·         the standard will apply to the providers of emergency care
service, including walk-in centres and other minor injury units - that could
be the acute trust or the PCT;

·         no patient should wait indefinitely - the backstop of the target
for time to admission after decision to admit (the 12 hour trolley wait
target) will stay in place;

·         we will discuss with CHAI how performance will be measured for
compliance purposes; and

·         hospitals are already collecting information on individuals. We
would only wish to see these if trusts found themselves in substantial
difficulties reaching and maintaining the operational standard.

Trusts should still be doing everything within reason to avoid any breaches
of the four hour target that aren't clinically necessary. Ultimately our
best guide to applying the Operational Standard rationally is the patient's
perspective. Patients need to know that if they need to visit an A&E
department they can expect to be in and out within a maximum of four hours,
and usually well within, except in circumstances that are genuinely and
obviously exceptional and explained to them clearly.



Effect on national reporting of total time



Trusts should note that the 2% tolerance from 100% has no effect on the
current national requirements for reporting of attenders and breaches.
Trusts at 98% will be considered compliant with the final target.



All attenders at A&E must therefore continue to be recorded. Of these, all
those that remain in A&E after 4 hours, whether for clinical or non clinical
reasons, must be recorded as over 4 hour waits and reported as such in
national data (SITREP and QMAE).



Status of national guidance



SHAs should also note that as SITREPs/QMAE are the data source for A&E
performance. It is essential for consistency that it complies with national
guidance. If for any reason you have departed from this, could you please
contact the national SITREP or QMAE team.



Star ratings 2003/04


I understand that CHI are about to issue the indicator set for star ratings.
Along with the indicator set, CHI will set out the period of measurement but
not how measurement against the target will be made.



Given that CHI will wish to present an accurate reflection of patient
experience, one possibility is that they will measure performance as an
average over the defined time period, similar to a number of the other key
targets.



I understand that CHI are unlikely to release information on thresholds.
However, over the history of performance ratings, thresholds on performance
have never been lowered, only raised. I strongly advise you therefore not to
make assumptions that the threshold for significant under-achievement on
this target will be the same as last year (85%) if it is measured as an
average. CHI may also wish to look at performance over the final quarter to
ascertain direction of travel. Again it is therefore important that you seek
to raise performance in your organisations.


Yours sincerely


JOHN BACON
Group Director

Health and Social Care Services Delivery