Daily Insight: The target that refuses to die

HSJ exclusively revealed yesterday that the latest bid to kill off the four-hour target – NHS England’s Clinical Review of Standards project, which was designing a basket of metrics to replace – has been effectively ditched by ministers.

Multiple senior figures familiar with the process, from inside the NHS and government, said the performance focus for the next two years will be on the two existing accident and emergency waiting time measures, as well as ambulance handover delays.

This represents a major blow to NHSE, which has spent the last three years lobbying government to scrap the long-standing target, and replace it with a bundle of measures which have been trialled at around a dozen providers. This work has been led by medical director Steve Powis.

HSJ understands the decision to continue using the existing four-hour target was driven by concerns among ministers and senior NHS figures that the bundle was too confusing, both for patients and as a means for government to hold the service to account.

Another driver was a landmark study published in early 2022, which laid bare the higher patient mortality associated with long waits in A&E and is also understood to have  caused significant alarm within Whitehall.

Going for the early tackle

Triage tough – that was the advice an NHS England director has offered to trusts when they are deciding whether to accept referrals from GPs.

Ian Eardley, NHSE’s joint national clinical director for elective recovery, told an internal NHSE webinar: “There’s got to be as robust triage as you can possibly do, so if you’ve got referrals coming in which haven’t got the relevant or wrong information, then I think you need senior clinicians in a position to go back to the GP and say we need this bit of information or the other… Ultimately, it’s about robust front-end management.”

However, he admitted it was a “difficult [issue and] really difficult to do anything centrally”. The webinar was recorded earlier this month and has been seen by HSJ.

Rob Findlay, a leading waiting list analyst, urged caution on this approach: “It is not so much what is done as how it’s done, and there would be a risk to patients if a hospital’s motivation for implementing ‘robust triage’ was the delivery of government waiting time targets, rather than the safe and effective management of patient pathways.”