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The results of our exclusive poll of senior NHS leaders’ views on the four-hour target lay bare the sector’s fundamental concerns about ditching the standard and the lack of buy-in NHSE has secured from leaders on its reform programme, writes James Illman

The vast majority of the NHS’ most senior leaders – more than seven in ten – do not want the four-hour target to be ditched, according to an HSJ survey published today.

And on this landmark question, about which debate has been muted if not stifled, this poll is the only barometer available of the views of the people running the NHS.

Other findings included:

  • Seventy-four per cent “agreed” or “strongly agreed” that “the four-hour target contributes to improved patient experience”); and
  • Seventy per cent “agreed” or “strongly agreed” that “the four-hour target contributes to keeping patients safe”

You can read the full story here on findings from our survey of 104 NHS board members.

Of course, there is a wide consensus that the four-hour standard is far from perfect. It is often gamed and drives some perverse behaviours. Most argue the urgent and emergency care performance regime, of which the four-hour target is the key component, is in need of reform.

But our survey suggests most still view the ageing target, introduced back in 2000, as a sound measure of operational pressure and as a driver of better safety and experience.

In short, it’s not perfect but it’s the best we’ve got.

If NHS England decides to ditch the target in April 2020 – or at some other point further down the line – as is widely believed that system leaders intend to do, the survey suggests they have a monumental task in terms of getting NHS leaders to buy into such a radical move.

We use surveys sparingly at HSJ because it’s hard to ensure the sample completely represents the whole population.

But we made an exception on this occasion because the questions could be posed in simple terms (despite the issue being horrifically complex); strong views have been expressed on both sides; the issue is so profoundly important; and – perhaps most importantly – because there has been a worryingly big gap in the debate so far, with many organisations and individuals afraid to raise concerns because they fear upsetting those at the top of NHS England.

Our sample represents a strong selection of key decision makers, with more than 60 per cent of respondents working as chief executives, deputy chiefs, chief operating officers or finance directors.

Over a third (34 per cent) of the remainder were chairs. At least one board-level respondent from more than 40 per cent of the NHS’ 145 acute trusts completed the survey.

The headline message also chimes with the anecdotal views I have heard since the review was announced last summer.

Trialing new metrics, however, is widely viewed as the right thing to do. The target’s shortcomings are well documented and a lot has changed in terms of clinical pathways since 2000. But the sense from many senior leaders is they do not want to chuck the baby out with the bathwater and lose the benefits of the four-hour target.

It was no surprise therefore that 67 per cent of respondents agreed the NHS should “introduce a new urgent and emergency care metric – but retain national reporting of the four-hour target”. Sixteen per cent of respondents disagreed with this statement.

This ‘third way’ keep-but-reform option is often floated by numerous respected and sensible figures. But it has a potentially fatal flaw.

As Siva Anandaciva, a long-standing expert on the four-hour standard and now chief analyst at the King’s Fund, told me: “Previous experience from developing the accident and emergency clinical quality indicators nearly a decade ago suggests that the four-hour target will remain king under this scenario and continue to suck up all the oxygen in the room.

“My message would be either move to a new measure of performance, or don’t move, but don’t get stuck in the middle as this will mean people just default to talking about the four-hour standard and ignoring any other metrics. “

However, he added: “If, however, the new measures are not demonstrably better… then I can understand why people will say, ‘well, why change them?’… The pay-off for the upheaval of changing how performance is measured would need to be substantial and clearly evident.”

This conundrum is a good illustration of how hard it is to reform the A&E standard, and the target review group should be cut significant slack as it grapples with how a more clinically appropriate set of measures could be configured.

However, fundamental questions are being raised about why NHSE continues to insist on running such a secretive process to trial the new metrics.

Numerous senior leaders have told me about the almost comic level of secrecy around the issue. They say it has stoked concern that those at the top want rid of the target, first and foremost because it cannot be hit, and that this is a political headache.

And NHS Providers has now called for a “fuller, transparent debate” with the wider NHS, public and politicians about potential changes to the NHS’ targets in response to our survey findings. 

A final point to make is the context within which this debate is taking place cannot be overstated.

The winter ahead is looking like it could see unprecedented pressure on the NHS with demand rising to record levels over the first quarter of 2019-20.

Northumbria Healthcare Foundation Trust chief Jim Mackey, who oversaw an aborted attempt to reform the target during his NHS Improvement tenure, told me: “If there is no improvement in the conditions in departments… but the numbers look better because we’ve moved to a new system, then both staff and patients will be very unhappy, and there will be consequences at some point.”

And that is a warning system leaders would be foolish not to heed.