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We revealed this morning that the Royal College of Emergency Medicine and NHS Providers — pivotal voices in the row over the future of the four-hour accident and emergency target — are both now signalling they are open to dropping it.

This represents quite a turnaround from RCEM, which only last month said there had been no evidence from recent trials of potential new urgent and emergency care metrics that there was a “viable replacement for the four-hour target”.

NHS Providers has publicly kept quiet until now. But that is in itself indicative of how difficult a decision it has been to back the ditching of a target which the majority of senior figures at its acute hospital members, at least, have been supporters of.

Both groups have set out a significant number of conditions (see piece for more on them) and there remain sceptics within both camps and in the wider NHS and policy world.

But the support of RCEM and NHSP represents a massive boost to NHS England ahead of the clinical standards review’s final recommendations, which have been expected later this month. The review is widely expected to recommend ditching the target.

With health and social care secretary Matt Hancock, patient representatives Healthwatch England, and other heavyweight royal colleges like the Royal College of Physicians also on board, surely this signals the four-hour target is brown bread?

But for a significant intervention from, say, Number 10, or some other remarkable chain of events, it probably is. Although, stranger things have happened and second-guessing this government (and the world in general at present) is a mug’s game.

But failing that unexpected twist — what does the replacement regime look like? 

Let’s start with the things we do know. There is consensus that no single metric can do the job, so there needs to a bundle of metrics.

This is sensible. So sensible, in fact it’s been tried a few times before. Nearly 10 years ago a basket of “eight clinical quality indicators” was devised by Matthew Cooke, the then national clinical director for urgent and emergency care.

NHS Improvement also tried something similar in 2016. The “A&E scorecard” was supposed to combine waiting time performance with clinical standards and data on staff and patient experience.

The failure of these projects to make the intended impact is testament to how difficult it is to pull together a bundle of metrics into something which is clinically meaningful, operationally useful, and understandable for staff and wider society.

Key parties on board

Why will it be any different this time around? Buy-in from almost all the key players is stronger this time round: NHS system leaders, government, patient representatives Healthwatch England and, critically, the royal colleges.

The reform agenda is driven, and driven hard and fast, by NHS England chief executive Sir Simon Stevens, and Matt Hancock is well on-board.

The change in heart at RCEM has been especially stark. While RCEM’s previous president Taj Hassan said only last year that “scrapping the four-hour target will have a near catastrophic impact on patient safety”, his replacement Katherine Henderson signalled her openness to reform as soon as she was in post.

But support for ditching the target is far from universal. A number of senior NHS chief executives have publicly raised concerns, some say they will retain the standard as a local measure, while clinical groups including the British Medical Association and the Society of Acute Medicine raised their concerns last month.

One thing which has not been achieved before, and which may be important, is putting a stop to measurement of the existing four-hour standard. This has not happened under the previous two attempts and, arguably, while it still exists, it will inevitably remain the focus. It is not yet clear how quickly the centre will seek to cease reporting it; some are keen for it to stay to allow historic comparison.

What’s in the bundle?

The metrics which will go into the bundle remain a live debate. And that debate has already been a long one.

The original focus on four measures in the emergency department has broadened into discussion of a possible systemwide basket.

Those initial four metrics, trialed by 14 trusts were:

  • Time to initial clinical assessment in A&E to “identify life-threatening conditions faster”;
  • Time to emergency treatment for critically ill and injured patients (including heart attack, major trauma, sepsis, severe asthma and mental health presentation);
  • Mean waiting time for all patients and strengthened reporting of trolley waits; and
  • Better utilisation of same day emergency care (also known as ambulatory care).

The clinical review of standards progress report in November went big on a mean waiting time target in particular — saying there had been promising results. It said that while overall waits had slightly lengthened by an average of six minutes, waits for admitted patients had been shortened and the total admissions had been cut (see box in this piece for more: Longer waits overall but less admissions, says NHSE pilot).

But senior emergency clinicians, backed by RCEM, said the mean target had incentivised the “wrong behaviours” including a focus on the swift treatment of less ill and non-admitted patients rather than the sicker patients. It also stripped individual patients of the right to a specific maximum wait.

While a mean time will likely still be part of the bundle, it will perhaps have a less prominent role than had been hoped.

System and clinical leaders are now also keen for the basket to represent pressures both up and down stream from the emergency department. This could mean bringing metrics like hospital bed occupancy and ambulance and 111 performance.

The major issue of which metrics will go into the bundle should be clearer by the end of the month when the CSR is due (covid-19 allowing) to publish its final recommendations.

But it appears, even after that, many key decisions will still be very much up for debate. As a result, it feels like the parties involved have now signed up to a direction of travel rather than anything resembling a robust plan.

As NHS Providers chief executive Chris Hopson put it: “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.”

RCEM meanwhile put forward the old chestnut that “the devil will be in the detail”.

The road ahead looks long and winding but, for now, there is senior buy-in, political will, and clinical support for change.