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Matt Hancock’s comments about the “old and inappropriate” four-hour standard suggest NHS England will not struggle to get his sign-off if they push for the service’s main target to go, despite the concerns of senior managers, says James Illman

The health and social care secretary made some very revealing comments about the four-hour target last week which went largely unnoticed, with NHS watchers far too caught up in the capital funding brouhaha.

Mr Hancock made the comments when he was on the BBC Radio Four’s Today Programme last Monday. He had been dispatched to staunchly defend the government’s disingenuous weekend claims that the NHS was receiving £1.8bn of new money.

But during the interview he was also asked about the NHS’ recent failure against all its core performance targets.

He said: “We have not had as much success as we would have liked in [meeting the NHS’ core performance targets], but it’s more complicated than that. We are also changing the way we measure success in the NHS…”

He continued: “The old four-hour target for A&E times was widely regarded by clinicians as an inappropriate target, because it meant sometimes they had the incentive of the target to treat one person, but then somebody who needed their urgent attention would come, and, of course, they would ditch the patient going for the target…”

Presenter Nick Robinson unfortunately cut in at that point to ask about cancer performance, so, Mr Hancock’s opining on the four-hour target ended there. But both content and tone were revealing all the same.

He called the four-hour target “old”, which appears a strange adjective to describe a target which is still the NHS’ main performance standard and will be until next year at least. If Mr Hancock chooses to describe the target as “old”, it seems unlikely that he views it as “the future”.

While he has previously said that clinicians view the target as inappropriate, it is still significant that he repeated this broad, hard to verify assertion. Because it would be strange, would it not, if the health secretary decided he wanted to retain a target despite having repeatedly cited clinicians’ apparent consensual view that it was “inappropriate”?

Finally, there was his reference to “changing the way we measure success in the NHS”, again, suggesting the status quo is not long for this world.

The tone is certainly very different to the interview he gave to HSJ last November.

In answer to the question ‘what would you do if a clinically-led review proposed scrapping the four hour target?’, he said: “It is a matter of whether the case is strong enough. So it’s not just about whether it’s recommended or not to change, it’s also whether the case to change is, in my view, watertight.”

He also stressed that public opinion would be a factor in any decision – which, of course, is political code for ‘will it lose us votes’.

Mr Hancock’s latest comments appeared to run contrary to the views of the majority of senior hospital managers. HSJ’s exclusive survey found last month that over 70 per cent of senior hospital leaders wanted to keep the target.

It is not, however, a message the NHS management sector has, until now, made particularly forcefully. Following our findings, NHS Providers called for a “fuller, transparent debate”. It said the “widely-held concerns” that system leaders wanted to ditch the standard because the system can no longer meet it, rather than for sound clinical reasons, needed addressing.

This is a valid point, but it remains to be seen whether such a debate will ever materialise. 

And while I’m not suggesting Mr Hancock is pre-judging the outcome of NHSE’s ongoing trial of potential replacement standards, he does appear to already be sympathetic to the view that:

(a) The four-hour target is clinically inappropriate; and
(b) The NHS needs to reform its target regime.

It would seem fair to assume that NHSE will have at least a sympathetic ear from the health secretary should it decide its review signals the four-hour target should be replaced by new metrics.

This is a major boost for those that want the target gone. The received wisdom has long been that ditching a target the NHS is not hitting, in this case for four long years, would be political madness – especially for a Conservative government. But perhaps the old rules simply do not apply anymore. 

This is, of course, not the only political hurdle NHSE would need to clear. It would be fair to assume that such a politically sensitive issue would require sign off from Number 10 and a likely snap election could further complicate matters.

I am not going to be foolish enough to try and predict how that could play out, but a health secretary so explicitly sympathetic to the reform cause further increases the likelihood of the four-hour target’s demise.

Axing the four-hour target is a good idea, if the new set standards are better for patients, clinicians and the system, and a terrible idea if they are not. A new system will also doubtless have faults, so it must be materially and demonstrably better than the existing one. Otherwise, why bother changing?

HSJ last week set out concerns about the pace of change (NHSE wants a new regime in by April 2020). A rushed approach will only raise the prospect of a botched implementation without securing sector wide buy in.