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NHS England’s desire to consider reforming the four-hour target is understandable. But an opaque process and tight timetable will only make an already tricky task even more challenging, writes James Illman.

Changing the four-hour target – should one want to – can only be done in the first year of a majority government with the backing of senior clinicians and will be far more challenging if the NHS is not meeting the 95 per cent standard.

So went the conventional wisdom about how to reform the health service’s most important constitutional standard.

But these are clearly not conventional times. And a bizarre set of factors – not least a weak, distracted government (or perhaps country) grappling with Brexit – have emboldened NHS bosses to think the unthinkable: to push for reform of the flagship target when the system is nowhere near hitting the four-hour standard and a minority government presides (and could fall at any moment).

A debate about the four-hour target, and the NHS’s other constitutional targets, is certainly well overdue, so there is much to welcome in the clinical review of standards, announced last June and due to report its findings in the spring.

Much has changed in how the NHS treats patients since 2004, when the accident and emergency target was introduced. And few would disagree with the theory of testing the validity of performance standards to ensure they incentivise best clinical practice and quality.

The target’s most ardent defenders, which include the Royal College of Emergency Medicine, would argue it already acts as a crucial quality measure as well as performance metric, but they would also concede it is far from perfect.

Few, for example, would disagree with the sentiment at least when Simon Stevens opined on the BBC Today Programme last week that the target “does not distinguish between turning up to A&E with a strained finger and turning up with a heart attack”.

The NHS England boss also said he would like to see a “tougher, faster set of standards for some major conditions like…sepsis, heart attack and stroke”. NHSE has since said a major focus of any reforms would be on “delivering the highest standards of care to those patients who need it the most” .

Again, few would disagree with the sentiment of prioritising the most in need. But senior emergency clinicians would rightly argue that this is what highly skilled ED staff already do.

A patient rushed in with a heart attack will not simply be left to wait because staff are too busy dealing with a strained finger – that is just not how it works.

And some senior figures told HSJ the push for tougher standards for the most urgent patients would inevitably require watering down standards for less serious conditions, given the relatively limited funding settlement.

The fears were expressed in the context of reports last month that proposals to drop the four-hour standard for “minor ailments” had already been discussed by the review team, as reported by HSJ.

But what if something quickly diagnosed as a minor, turns out to be more serious, or ultimately fatal?

Mr Stevens used sepsis as an example of something he wanted to see dealt with more swiftly (it is already recommended that it is dealt within one hour). Sepsis is a prime example of a disease for which the symptoms can be dangerously hard to spot and, on early examination, often appear to be less serious.

Much like sepsis, unravelling the four-hour target for minors is a far more complicated job than it might first appear – and errors in doing so will have tragic consequences.

And, of course, those proposals to ditch the target for minors did not come out of thin air. The idea was floated by then health secretary Jeremy Hunt as recently as 2017, after an NHS Improvement review of the four-hour standard (but quickly shot down).

And some system leaders are understood to still be sympathetic to at least robustly testing out such a policy.

A major driver for this thinking is that it could help address another of the NHS’s undeniable problems: that many A&E attendees with minor ailments (the actual amount is hotly debated) would be more appropriately treated elsewhere.

Such a move would, of course, spark accusations that system leaders were, among other things, watering down a standard that isn’t being met and trying to fiddle the figures.

And so onto the third piece of conventional wisdom from more sober times: that any proposals must have the backing of independent senior clinicians, especially the relevant college – in this case the Royal College of Emergency Medicine.

A mundane set of factors, disagreements and political squabbles have, however, led to the college being cut out the loop by NHS bosses in a number of instances in recent times, including its exclusion from National Emergency Planning Panel last winter.

And, as revealed by HSJ today, the college has said it has not been formally consulted on target reform since 2017, which it called both “surprising and seriously concerning”.

NHSE did not contest this when invited to comment by HSJ, although it did say it was consulting with the umbrella organisation which lobbies on behalf of all the colleges, the Academy of Medical Royal Colleges.

But concerns about the process have been raised to HSJ from far wider afield than just RCEM – both in terms of senior clinicians and managers.

One respected figure told HSJ the intention set out in the NHS planning guidance last month to “begin implementing” new emergency targets from October was “extremely ambitious…brave” and left little time for meaningful consultation.

The view was shared by several other senior figures HSJ contacted, with the October deadline only further heightening concerns the review will not carry out a robust consultation.

Many have also contrasted the apparent rush system leaders appear to be in with the ambulance response programme.

The ARP resulted in an entirely new set of targets being fully implemented from October 2018 and was widely viewed as a successful implementation of a politically sensitive set of standards which could be used as a template for further reforms.

But it took several years – and still isn’t completely finished. Full rollout of the new ARP targets followed a comprehensive clinical evaluation from the University of Sheffield and a pilot programme which began in 2015, three years before universal implementation.

It is hard to see how the process for a far more high profile political target like the four-hour standard could be wrapped up in a matter of months should the review recommend reforms beyond tinkering around the edges.

Whatever the direction the review ultimately chooses, a peace deal between RCEM and NHS England and Improvement and wider engagement with the sector would both be welcomed as the review moves towards the business end of the process ahead of recommendations being published in the spring.