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Royal College of Emergency Medicine – Breach exemptions Q&As

To assist in the understanding of ‘Breach Exemptions’, their application, and impact on official A&E performance data in Wales; and the data obtained by the Royal College of Emergency Medicine under the Freedom of Information Act regarding A&E attendances and waiting times in Wales for the last decade, the College has compiled the following Q&A.

Where did you get your information?-

The Royal College of Emergency Medicine sent Freedom of Information requests to Health Boards in Wales asking about A&E waiting times in Welsh Hospitals and the policy around ‘breach exemptions’.

What’s a breach exemption?

Breach exemptions – also known as ‘clinical exceptions’ are defined in this 2011 policy document:

  • If a clinician decides that the safest place for a patient is the Emergency Department, the patient should remain there until it is safe to move them; and /or
  • Patients should not be admitted solely to avoid a breach of the four-hour target. Clinicians should admit patients only to appropriate facilities and only when it is appropriate to do so.

These patients are broken down into two broad categories:

  • Those who need the facilities of the main emergency department, often the resuscitation room.
  • Those who are cared for by Emergency Medicine specialists but do not need the specific facilities of the main department (ie best cared for in a ward environment, for example an observation area or clinical decision unit that is adjacent to the main department)

The only exceptions to the target are those cases where it is believed that clinical care is best undertaken in the main emergency department.

What was the wording of the Freedom of Information request?

“Using the Freedom of Information Act 2000, I am writing to request the total number of patients who have waited 4-hours or more and also 12-hours or more in the XX Emergency Department, XX Hospital, for each month since breach exemptions were introduced in 2011 to present day. I am requesting that the data include the patients that were removed from the published data due to breach exemptions.”

What did the responses to the Freedom of Information requests tell you?

In the first six months of 2023, there were 45,757 patients who were classified as ‘breach exemptions’ and therefore their true length-of-stay in A&E had not been recorded, included or reflected in the official performance data.

Their attendance, and waits are recorded in the data but in the ‘less than four hours’ category when in reality it could be much, much longer.

Since January 2012, the number of people who have been misrepresented in this way is 673,787.

Are you saying that in the first six months of 2023 more than 45,000 people have been excluded from the data entirely?

No. The attendance of these patients is recorded and included in the data published.

It is the true length-of-time that these patients wait in A&E that has not been accurately reflected in the data.

They have been excluded from the ‘waits of more than four-hour category’:

Patients have been described as ‘missing’?

Yes. These patients are ‘missing’ from the correct portion of the data (waits exceeding four hours).

They are not missing from the whole data. You could also say they are being ‘mis-categorised’ or ‘not included in a category which accurately reflects their true length of wait’.

Patients, who are classified as ‘breach exemptions’ may wait more than four-hours, eight-hours or more than 12-hours in A&E and this waiting time is not published.

Who decides which patients have a breach exemption applied?

We cannot say for certain. We have limited data about this, as local procedures may vary. We would welcome, and will seek, further clarity from Health Boards about how the policy is applied in practice.

How long have breach exemptions been used?

The policy for ‘breach exemptions’ was introduced in 2011. They were introduced to monitor patient flow in A&Es and to prioritise patient care. The argument was that for some exceptional patient cases, remaining in A&E was the safest option. For example, patients undergoing active resuscitation, patients with concussion who remain in the A&E for observation, or even a patient awaiting test results.

Are you saying the published data is not in accordance with the breach exemptions policy?

No. RCEM does not claim that the published data is not in accordance with the 2011 ‘breach exemption’ policy.

What is RCEM’s position?

RCEM believes that the application of the ‘breach exemption’ policy is misleading, and the published data is not reflective of the scale of long waits taking place in Welsh A&Es. Furthermore, the policy leaves too much room for interpretation, and there is a lack of continuity on how it is applied.

This lack of transparency is bad for clinicians and Emergency Medicine, but most worryingly it is bad for the patients.

What is the Welsh Government saying?

The Welsh Government has said: “…Welsh Government statisticians do not exclude clinical exceptions from the data received from DHCW [Digital Health Care Wales].”

This is their full statement.

Is RCEM disagreeing with the claims of the Welsh Government?

No. RCEM does not dispute that these ‘clinical exception/ breach exemption’ patients are included in the published data.

RCEM is saying that the published emergency department performance data does not reflect the true length-of-stay faced by those patients to whom the policy is applied. And that recording patients who have had a ‘breach exemption’ applied in the waits of less than four hours category misrepresents the true picture when it comes to A&E performance and waiting times.

Is there a comparable policy in other UK nations?

From information provided to RCEM we understand there is no comparable ‘breach exemptions’ policy or practice in any of the other UK nations.

Why has RCEM called out the policy of ‘breach exemptions’?

As part of its campaign #ResuscitateEmergencyCare, RCEM is calling on UK governments to introduce transparent ways of measuring how hospitals are performing so we know which ones need to improve

RCEM believes the policy of ‘breach exemptions’ means published emergency department data in Wales is not transparent.

What does RCEM want to happen?

RCEM Wales continues to call on the Welsh government to publish fully transparent and meaningful data – by either removing the policy of ‘breach exemptions’ altogether or routinely publishing the data before the ‘breach exemptions’ are applied.

Why are A&E waiting times important?

Long delays to receive emergency care are harmful to patients and are associated with increased mortality. RCEM is campaigning to put an end to overcrowding and dangerous delays as part of its campaign to #ResuscitateEmergencyCare.

Why is transparent data important?

To tackle overcrowding and dangerous delays you must see and understand the true scale of the problem. Transparent data is the first step towards achieving that goal.

Do RCEM members and Emergency Medicine clinicians agree?

In June 2023, RCEM surveyed EM clinicians from all Health Boards in Wales about the policy of breach exemptions and found that:

  • 100% of respondents said that the Government should publish figures without the application of breach exemptions.
  • 82% of respondents said that the policy should be totally scrapped.

What steps has RCEM taken up to now?

In 2021 RCEM made an evidence submission to The Health and Social CareCommittee consultation on Sixth Senedd Priorities where we called for the policy to be scrapped.

In November 2022, RCEM sent a letter to the Welsh Health Minister calling for data to be published without the application of breach exemptions. This letter was signed by clinical leads from each emergency department in Wales. The Minister replied that the guidance would not be scrapped.

We have issued a series of comments about this issue and frequently raise it at meeting with health officials in Wales.

RCEM has also published this more detailed briefing about ‘Breach Exemptions’.

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