Welcome to HSJ’s Performance Watch expert briefing. Our fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.

Details on how the NHS targets review will progress are expected imminently amid signals ministers will back system leaders if they develop credible reform proposals and avoid the bear traps, which have thwarted previous attempts.

The gauntlet has been thrown down to NHS bosses to seize an opportunity that will not come around again for a while.

An announcement around the broad direction of travel for how the review will work is understood to be included as part of an update on the NHS long term plan, which senior sources said was expected imminently.

Health and social care secretary Matt Hancock has indicated he is open to reform and would be prepared to back NHS plans should they be credible.

No one is expecting any decisions on target reform to have been sorted by November. And that’s a good thing. Genuine reform will not be a quick fix and anything other than a lengthy process involving full public and clinical engagement will quickly be called out and crushed by a sceptical media.

As discussed in Performance Watch last time any attempt to reform targets, especially when performance is so poor, will inevitably attract suspicion. The exercise is just a ruse to water down targets and with it care quality, sceptics will say.

To show this is a genuine attempt at reform to deliver better outcomes and not just a means of watering down standards, I think system leaders will need to demonstrate they are on the right side of three red line principles:

  1. Any changes must be supported by robust, independently verified clinical evidence base for any changes.
  2. If there are new targets, they must be demonstrably delivering a level of performance better than, or the very least no worse, what should be being delivered if the existing statutory standards were being met.
  3. The debate must be whiter than white in terms of transparency and how staff of all levels and patients are engaged.

NHS Providers chief executive Chris Hopson summed up the conundrum facing policy makers neatly. He said: “There appears to be growing consensus on two broad principles. Firstly… We shouldn’t abandon the overall performance levels implicit within [the current waiting time targets on A&E, elective care, and cancer].

“However, the second area of broad agreement is that these targets are crude, do not always reflect detailed patient need or current clinical practice and risk driving clinically inappropriate approaches.

“The question the detailed work will need to answer is whether we can find a way of meeting these two principles simultaneously.”

Reforming the NHS’s headline accident and emergency target was addressed in the last Performance Watch. But there will be plenty of debate around the NHS’s other headline statutory targets, especially the referral to treatment 18 week target and the cancer targets, an area earmarked for fresh resource from the long term plan.

A shift to outcomes based cancer targets?

Could we finally, for example, see a shift towards a focus on outcomes rather than waiting times for cancer as has long been promised?

The Department of Health and Social Care’s review of cancer waiting time standards back in 2011 pledged to “focus on outcomes rather than process targets, except where the latter are clinically justified”.

Yet fast forward to 2018 and the financial incentives are still solely based on waiting time targets: the 14 day referral to specialist; the 31 day diagnosis to treatment; and the 62 day targets from referral to treatment targets.

A new target is due to be introduced in 2020 – but that is another process target (a new 28 day diagnostic waiting target to replace the existing 14 day standard).

John Baron, a former shadow health minister who stood down last month after chairing the All Party Parliamentary Group on Cancer for nine years, told me the review was “a golden opportunity” to introduce an outcomes based statutory cancer target.

The former shadow health minister said: “A focus on one year survival rates would encourage a big push on early diagnosis. The NHS’s relatively poor performance on early diagnosis is one of the main drivers for why we lag against international averages.”

Reform that supports early diagnosis would be supported by the NHS cancer leadership community, both in terms of delivering better patient outcomes and saving money long term, as we discussed here.

But how best to do that remains an issue of great contention.

Roger Spencer, chief executive of leading cancer hospital The Christie Foundation Trust, indicated his support for waiting times. The well regarded figure told HSJ last month the good work on treatment times “must continue, of course… [but] if we could bring the same level of performance management and scrutiny to early diagnosis we could make a huge impact on outcomes, and save money in the long term”.

No one is saying that any of this will prove remotely straightforward or that there are any solutions that can be plucked off a shelf.

But if the NHS does not seize the opportunity to update targets, the existing targets regime could well be baked into the long term plan. It could be a long time before there is another chance to update the targets, some of which were established nearly 20 years ago.