Thank you for the opportunity to discuss the concerns raised by the Health Service Journal about comments made at NHS England and Improvement’s joint Board meeting on 28 March about winter performance in NHS hospitals in England. It has been reported that coding issues with same day emergency care (SDEC) patients were cited as a reason why four-hour A&E waiting time performance did not improve this winter, despite the more favourable weather conditions and lower flu and norovirus prevalence than in the preceding winter.
We have worked with you previously to highlight the importance of maintaining the trustworthiness, quality and value of A&E performance measures in England. Any suggestion that data integrity is compromising the statistics’ ability to accurately capture service performance is always concerning.
You have told us that SDEC is a new way of delivering care to patients whose needs are not always best met by a traditional A&E attendance. You outlined that analysis of the Admitted Patient Care dataset highlights that a number of trusts report patients with conditions amenable to same day emergency care as being admitted to hospital. These patients therefore appear in the non-elective admissions statistics where they are recorded as admissions of zero days’ length. In recent months you have started to show the zero and 1+ lengths of stay non-elective admissions separately to highlight the differential growth rates of these two elements. This separate presentation allows users to estimate the impact of SDEC patients on non-elective admission rates.
We understand that the impact of SDEC treatment on A&E performance is harder to quantify. However, you think it unlikely that they account for this year’s performance in the way reported. In some cases, a patient can have an A&E attendance recorded if they present at an A&E before they are redirected to SDEC. Typically, these types of attendances are short, so these patients would be recorded as having been seen within four hours, whereas they were actually redirected to an alternative form of care. The number of SDEC patients is currently small compared to the volume of patients seen in A&E, and the subset of SDEC patients who first present at A&E is smaller still. For these reasons, you are confident that the statistical impact of recording SDEC patients as short A&E admissions is likely to be very minimal. You have provided assurances that appropriate steps are being taken to adapt systems to improve the recording of SDEC patient journeys.
As the statistician responsible for guaranteeing the integrity of NHS England’s statistics, we recommend you seek assurance on:
- The number of SDEC admissions versus the number of A&E attendances;
- The number of SDEC admissions who are also recorded as an A&E attendance.
The introduction of new ways of delivering care, and of measuring performance, brings numerous challenges for statistics production. It is important to raise awareness of these challenges and to be transparent about the steps being taken to maintain the trustworthiness, quality and value of NHS England’s statistics. This is particularly important if there is any perception that measures have been changed in order to mask performance failures. We recommend you publish details of your work to safeguard the integrity of these statistics, for example via blogs or special articles in the coming months.
Director General for Regulation
Ed Humpherson to Mark Svenson, November 2018