• Royal College of Emergency Medicine and NHS Providers give conditional support for reform
  • NHS standards review set to announce recommendations later this month
  • Ditching four-hour target would represent biggest targets shake-up in 20 years

The Royal College of Emergency Medicine and NHS Providers — important voices in the row over the future of the four-hour A&E target — are both now signalling they are open to dropping it, HSJ can reveal.

The news comes at a crucial stage and suggests it is very likely NHS England and the government will be able to forge ahead with plans to ditch the four-hour standard. NHSE’s intentions are expected to be set out in the final recommendations of its targets review due this month.

Both RCEM and NHS Providers told HSJ this week they were likely to back the NHSE clinical standards review’s emergency care plans, which are likely to propose a new “basket of measures” to replace the existing four-hour standard. Both organisations also set out conditions which should be met, however. 

The move to scrap the target, which health and social care secretary Matt Hancock has openly backed, would represent the most significant shake-up of the NHS performance regime in nearly 20 years.

The willingness of RCEM in particular to back a change represents a huge boost for those who have been pursuing it.

Senior emergency medics and NHS managers have long been among the four-hour target’s most ardent supporters, with RCEM’s previous president stating last year that “scrapping the four-hour target will have a near catastrophic impact on patient safety”.

Current president Katherine Henderson has signalled a more open stance to reform but warned only last month there had been no evidence from recent trials of new measures that there was a “viable replacement for the four-hour target”.

But the college told HSJ yesterday that “since January significant progress has been made and we are now seeing signs that a bundle of measures” could be viable.

“There is still a way to go and the devil will be in the details,” a spokesman added (See box: RCEM’s full statement).

The bundle of measures referred to in the statement have been trialled by 14 acute trusts since last summer. Only small samples of their data have been made public so far, and there has been no external validation.

The potential metrics include an average waiting time in accident and emergency, as well as shorter targets for the most sick patients, and how long patients wait for a first clinical assessment, a metric backed by Healthwatch England last month.

There is consensus no single standalone metric can do the job any more, and that a bundle of measures is therefore the best option.

But it remains to be seen what the review will recommend in terms of how any bundle of metrics is configured and reported, and what will be used as a proxy for system-level performance — a role currently played by the four-hour target.

NHS Providers, meanwhile, represents senior leaders of trusts — a group which expressed significant backing for retaining the target in an HSJ poll last July.

The lobby group, however, said after significant consultation with members it was open to scrapping the four-hour target. But only if “five key conditions” around credibility, clinical support, funding and patient engagement were met (See box below: NHS Providers’ five key conditions).

NHS Providers chief executive Chris Hopson told HSJ the five conditions could be met by national leaders, but they set an “extremely high bar” for a new standards regime.

The lobby group — which has not previously come down for or against a change to the target — sets out its position on potential changes to a range of core NHS targets in a report, Setting good standards for NHS patient care, published today (See PDF attached).

 NHS Providers’ five key conditions

 NHS Providers believes trust leaders will support any change to the standards if five key conditions are met:

1. There is a strong, clear, and widely supported, clinical case for change.

2. New standards are meaningful to patients and the public.

3. Trust leaders are fully involved in the design, consideration and implementation planning of any changes.

4. Implementation planning is realistic and honest about what resource and time is needed to make any change, taking full account of current operational problems.

5. It is demonstrably clear the changes are not an attempt to abandon the inherent performance in the current standards and that there is a credible, fully funded, agreed, plan to recover those inherent performance levels.

Mr Hopson said: “We don’t see now as the end of the process. The next stage of the process will be [NHSE] coming out with some proposals about what should happen. [NHSE] and the government have committed that there will be an appropriate level of discussion.

“As part of all that there then needs to be… A discussion about implementation and rollout… If the process means every single trust adopting the new standards… I think we’re looking at least 12, 18, 24 months away from that.”

Mr Hopson also said the debate had to move on from purely clinical issues to operational ones.

This included having a “legitimate currency converter” to measure “future performance against historical [four-hour] data”. “There would be a very significant problem,” if this was not possible, he said.

He said the four-hour standard is “one of the key organising principles for how [emergency] departments work”. IT, system flow, and the way the staff are configured in hospital were all influenced by the target, so moving to a different system would require time and money, he warned.

An NHS spokesman said: “We’ve been grateful for the extensive and constructive input on this issue from clinical groups, local leaders and patient representatives over the last 21 months, and intend to set out recommendations shortly which reflect what patients and the public want, and support staff to provide the high quality care we all want to see.”

RCEM statement in full: A bundle of metrics may be viable

A RCEM spokesman told HSJ: “We have been actively engaged in the process of reviewing clinical standards. We are fully aware that changing standards does not change the reality of an underresourced system.

 “Over the last year we have seen various data collected that has emphasised how complex the system is and that a single, standalone metric cannot describe quality or wider performance in a meaningful way.

“Since January, significant progress has been made and we are now seeing signs that a bundle of measures, rather than an outright single replacement, may be a viable way to help drive flow, reduce overcrowding, improve quality, and foster a safer environment for our patients and staff. There is still a way to go and the devil will be in the details.”