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Reforming urgent and emergency care performance management

  • Last modified date:
    18 July 2011
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In line with the Government's commitment, outlined in Equity and excellence: liberating the NHS, to hold the NHS to account against clinically credible and evidence-based outcome measures, the Department of Health is developing some clinical quality indicators for urgent and emergency care.  They will be consistent with the NHS Outcomes Framework. The NHS started using the first sets of clinical quality indicators, for A&E and ambulance services from April 2011.

Urgent and emergency care system performance

When a patient needs urgent or emergency care he or she often needs care from more than one NHS organisation.  It is important that NHS organisations work together to provide seamless care from the point of view of the patient.  The way performance is measured needs to take this into account and therefore we are developing some clinical quality indicators that will demonstrate how well the whole urgent and emergency care system is working in each area.  These indicators are being developed by the Department of Health with clinical partners with a view to having these in place for 2012/13.  More information about them will be published when they are fully developed.

Accident and Emergency services

On 17 December, the Secretary of State announced the introduction of a set of clinical quality indicators for A&E services from April 2011.  They replace the standard set by the previous Government that no patient would spend more than four hours in accident and emergency (A&E) departments from arrival to admission, transfer or discharge.  They were developed by Professor Matthew Cooke, National Clinical Director for Urgent and Emergency Care working with the College of Emergency Medicine, the Royal College of Nursing and lay representatives.

The purpose of the clinical quality indicators is to provide a more balanced and comprehensive view of the quality of care.  This includes outcomes, clinical effectiveness, safety and service experience, as well as timeliness.  These indicators remove the isolated focus on achieving faster care at the expense of higher quality care.  The clinical quality indicators also aim to stimulate a more sophisticated discussion and debate about quality of care to support a culture of continuous improvement.  Each A&E department will present data on performance against the indicators on their website, as well as some narrative text to explain what their performance means and how they plan to continuously improve their service.

A&E departments will use the results of the indicators, benchmarking their own site against other sites with similar profiles, to gauge performance and identify improvements.  Commissioners will be able to use the indicators to set goals for improvements in the quality of the care they are commissioning.  In addition, in 2011-2012, the Department of Health has included the indicators in its approach to performance management under the Operating Framework for the NHS in England .  More details of the indicators, their definitions and how they will be used can be found in the following documents:

The four hour A&E standard continued to apply until March 2011.  In 2010/11 97.4% of patients spent less than 4 hours in A&E.  Statistics for individual trusts are published every quarter as part of the Department’s Quarterly Monitoring of A&E dataset.

Ambulance services

On 17 December 2010, the Secretary of State announced the introduction of a set of clinical quality indicators for ambulance services that will take effect from April 2011.  This set of 11 indicators will replace the Category B, 19-minute response time target, which has no clinical justification and will therefore see a move to an ambulance service that measures its performance on what matters most to patients and the NHS – quality and patient outcomes. The indicators will apply to all ambulance calls.

Peter Bradley, National Ambulance Director, working with key partners and clinicians within the ambulance service, has developed the set of indicators; that are intentionally aligned with those for A&E.

With the removal of the Category B, 19-minute response time target, the ambulance clinical quality indicators will give a better indication of patient care and experience. They will encourage discussion and debate in the local NHS and promote a culture of continuous improvement.

Timeliness of care will still be an important factor – as it is not acceptable for unnecessary delays in care to increase. But crucially time will not be the only factor.

Importantly, the ambulance clinical quality indicators will improve the quality and safety of care by focussing on those groups of patients who need the most urgent care rather than according to the category of the call alone.

More details on the ambulance clinical quality indicators will be published by the Department in the New Year.

Ambulance services will still be required to respond to Category A (immediately life-threatening) patients in 8 minutes, and provide transport (where needed) to these calls within 19 minutes, as set out in the NHS 2010/11 Operating Framework as existing commitments. These are

  • “A8” - 75% of Category A (immediately life threatening) calls should receive a response within 8 minutes – this initial response can be by traditional ambulance or a range of other options including car, motorbike, volunteer community responder.
  • “A19” - If a Category A patient requires transport, this should arrive within 19 minutes of the request for transport being made, 95% of the time

 Response time targets are reported annually to the Information Centre (IC) by all NHS ambulance trusts, which the IC then publish in the KA34 Annual Statistical Bulletin.

GP out-of-hours services

From 1 January 2005, all providers of out-of-hours services have been required to comply with the national out-of-hours Quality Requirements.  These were first published in October 2004 and clarifications were issued in 2006.

Following publication in February 2010 of the report by Dr David Colin-Thomé and Professor Steve Field on their review of the local commissioning and provision of out-of-hours services, the previous Government committed to reviewing the national quality requirements.  The Department of Health is taking this forward in light of the Coalition Government’s commitment to delivering a coherent 24/7 urgent care service in every area of England.  More details will be published when this work is further developed.

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