Why are performance targets being reviewed?
The four-hour A&E waiting time target was brought in 15 years ago and sets out a national standard that at least 95% of patients attending A&E should be admitted, transferred or discharged within four hours.
The NHS is reviewing this measure as well as other national targets in elective care, cancer, and mental health, to reflect the changing environment so that people receive the best possible care.
The NHS Access Standards Review proposal includes:
- The introduction of average waiting time measures. This would mark a move away from maximum waiting times, such as the four-hour A&E target and 18-week target for routine operations.
- New measures to support faster initial assessment and treatment for those with the most urgent needs.
What do people think about the measures?
To ensure people’s views are considered in NHS England’s review of targets, we polled 1,700 people in July and October 2019.
Awareness of current targets is low
Despite intense media scrutiny of A&E targets, only one in five people (21%) knew what the national A&E target was. Of those who thought they knew, 71% correctly selected four hours as the current target.
Less than one in five (17%) correctly identified the “Referral to Treatment” (RTT) target of 18 weeks for routine, non-urgent operations. One in three people believed the standard time for treatment was between six months and 12 months.
People aren’t clear when the clock starts ticking
Less than half correctly identified that the total time patients spend in the A&E department is measured from the moment they register with reception.
One in three thought time in department was measured from when they arrived, which means they could perceive their wait time as longer than what is measured by the NHS.
For non-urgent operations, only 12% of people correctly identified that the ‘clock starts’ when the hospital receives and acknowledges the referral. One in five people believed waiting times for routine treatment were measured from their first appointment with a GP about the issue, and two in five said it was from the point a GP sent a referral to the hospital or other specialist service.
Like with A&E, this raises the possibility of discrepancy between what people perceive as their waiting time and the actual measured waiting time.
Average waiting times are easier to understand and more helpful
When asked about what would be most meaningful to them, 70% of people felt an average A&E waiting time measure was easy to understand, higher than any other option. People also thought it would be more helpful for setting expectations, compared to how targets are currently reported.
For routine operations, people also said they felt average waiting times would make it easier to compare local services, helping them to make more informed choices about where to seek urgent care or plan to go for treatment.
To ensure this information is useful, people wanted more specific information about waiting times for their condition.
While people clearly preferred average waiting times, the research also showed rising levels of concern about having to wait longer than the average. Whatever approach the NHS takes, it’s vital that services do more to communicate to patients what they should expect when it comes to waiting times, and to offer interim support measures while people wait.
Waiting times are less important to people than other aspects of their experience
We asked people to give a priority rating of 1-5 for twelve aspects of care in A&E. We found that time spent waiting is less important to people than quick and effective triage, clear communication, access to pain relief, and quality of care.
This is consistent with our previous research carried out earlier this year.
What's most important to having a good experience in A&E?
We asked people to rate a series of factors based on what they think should be prioritised in A&E.
1. Prioritise treating patients with the highest level of need (89%)
2. Deliver the right tests and treatment within an hour where people are thought to have a life-threatening condition (88%)
3. Assess patients quickly on arrival so that their level of need can be determined (86%)
4. Offer pain relief while waiting if appropriate (71%)
5. Give people an estimated waiting time on arrival and informing them of any changes (65%)
6. Ensure staff are on hand to provide support while people wait to begin treatment (63%)
7. Admit or discharge all patients as soon as possible (62%)
8. Make information about current waiting times available to people before arriving at A&E and provide information on alternative services (59%)
9. Make sure that people who have been in the A&E department the longest are prioritised (50%)
10. Communicate to patients that a safe number of staff are working (49%)
11. Help people to avoid being admitted to a hospital ward overnight wherever possible, even if that means they spend longer in A&E (48%)
12. Admit or discharge a set proportion (currently 95%) of patients within a set timeframe (currently four hours) (46%)
The percentages reported reflect the proportion of people who gave each factor a high priority rating (4+ on a scale of 1-5).
One in ten are happy to wait ‘as long as necessary’ to be treated and discharged for a non-urgent condition
Most people (81%) told us that they would expect an initial assessment in A&E within 30 minutes of arrival. Four hours or below (the current national target) was generally thought to be an acceptable time to wait to be treated and discharged for a non-urgent condition. However, 11% thought it was acceptable to wait ‘as long as necessary’.
While the current waiting time standard is broadly in line with people’s expectations, some do not have any defined expectation for waiting times as long as they know they will be seen.
Although many people visit A&E without seeking external advice, most are advised to attend by another service
A&E departments have been under increasing pressures in recent years. There have been some suggestions in the sector that demand could be lessened if more people sought clinical advice before going to A&E. Our research shows that most people are already doing this.
62% of people who had visited A&E in the last three years said they had called 999, or been referred by NHS 11, their GP, or another professional. (Respondents could select more than one option).
In fact, people prefer not to go to A&E. 73% of people told us their experience would be better or much better if they were able to make an appointment at the service they needed by calling 111 and waiting at home until their appointment.
81% of people would be more likely to call 111 before going to A&E if they knew that they could be booked directly into an urgent appointment that would suit their needs. This service is already on offer in some areas, but our polling shows that a further roll-out would be popular.
People are willing to seek alternative options to A&E and would be even more willing to do so with increased confidence that seeking advice before going to A&E will result in an efficient response to their needs.
Most people are not told how long they should expect to be in A&E when they arrive
Only 22% of people who have been to A&E in the last three years said that they were informed about waiting times when they arrived. As our polling shows, keeping people informed and managing expectations should be a high priority in A&E. Addressing this could have a positive impact on people’s experiences.
Time in department is not the best indicator of people’s overall experience of A&E
Our research highlights that waiting time is not the main priority when people consider the quality of their experience in A&E. 69% of people who visited A&E in the last three years said they were satisfied with their overall experience, even though not all of these people were satisfied with the length of time they waited (54%) or the communication they received during their visit (47%).
People also appreciate NHS staff, with 78% saying they were satisfied with staff attitude. More broadly, it points to the fact that people understand the pressures that A&E departments are under and are willing to give the NHS the benefit of the doubt. However, services need to ensure they listen to what people want to continue improving care.
We are working closely with the NHS to identify opportunities to improve people’s experiences in A&E. Six local Healthwatch are speaking to patients in test sites currently piloting new A&E access standards, to understand how the proposed measures will impact people.