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A timely report published this week by well-regarded NHS researchers says there is an argument for reforming the four-hour target, just as performance against the totemic target deteriorates to a record low.

The report by the Strategy Unit, an NHS-owned consultancy group, comes just weeks ahead of the NHS targets review group’s deadline to announce its recommendations and just a week after official figures revealed performance against the accident and emergency waiting target had hit yet another record low.

The unit also analysed the reasons performance had deteriorated so much since 2010.

Overall four-hour performance was 84.4 per cent in January against the 95 per cent target, while in major Type 1 emergency departments it dipped to 76.1 per cent.

This was despite norovirus and flu having generally been lower this year than last. While January was cold, there’s been nothing as severe as 2018’s Beast from the East.

Major problems have historically been confined to a relatively small number of health economies, but that pool is growing and nearly everyone is now feeling the pinch.

The struggles of normally high performing trusts like Frimley Health Foundation Trust (82.7 per cent for Type 1 in January) and Surrey and Sussex Healthcare Trust (81.7 per cent) drag stats down ever further, and add weight to the persuasive narrative that the NHS is running on empty.

Several senior sources I spoke to put the latest deterioration down to pressure gradually accumulating over time. The last 24 months, at least, have been relentless, and this means the emergency care system has much less resilience that it did a few years back.

“The poor data from January was not the surprise,” one battle hardened NHS manager told me this week. “The surprise was that the data for November and December wasn’t equally bad.”

A bad Monday could be shrugged off in years gone by and performance pulled back in line early in the week. But many are finding this winter that a bad Monday can knock them out of kilter for the whole week, another seasoned hand observed.

The anecdotal evidence is supported by the report by the Strategy Unit, which is hosted by Midlands and Lancashire Commissioning Support Unit.

It concludes that departments are now “less resilient, taking longer to recover from periods of pressure than in the past”. It identifies several causes of the decline since 2010 including:

1. Greater complexity and acuity of patients: a well-publicised problem driven largely by a population with more older people and more people with long-term conditions.

2. “Exit block theory”: bed occupancy has increased because of problems with discharge, causing knock-on delays in emergency departments.

3. Increased admission thresholds/efforts to cut emergency admissions: less complex work is being streamed away, leaving the department with the more complex cases.

4. Staffing and physical resources (e.g. cubicles, trolleys) have increased faster than the number of attendances – but have not kept pace with changes in casemix and practice intensity.

And where do we go from here?

The Strategy Unit paper says there is an argument for looking at reforming the target and that more “nuanced” approaches “may be worth considering”.

It says “there may be an argument for adjusting or stratifying the performance target to reflect differences and changes in casemix”, although it warns the performance deterioration cannot “be explained by casemix changes alone”.

It adds that “casemix adjustment is not without its challenges, but it is an approach commonly used” in other clinical specialities.

In another interesting recommendation, the report advises: “Policy makers may wish to consider commissioning a thorough review of the evidence relating to the circumstances in which tests and investigations in A&E add diagnostic value. Reducing the frequency of low value tests could lead to reductions in A&E attendance durations without increasing admissions.

“The notion that changes in diagnostic imaging capacity and the availability of specialists to review patients might have led to changes in four-hour breaches is underpinned by sound theory but is difficult to evidence in practice using national data sets.”

The conclusions come with NHS England’s target review group, led by medical director Steve Powis, preparing recommendations for publication next month.

Changes to the A&E target are on the cards with Professor Powis understood to be keen on reform, as are NHS England’s chief executive Simon Stevens and chair Lord David Prior.

The nature of those changes is still being thrashed out and a lively debate is ongoing, with the Royal College of Emergency Medicine, among others, determined to block any efforts to water down the standard.

Both target ‘reformers’ and ‘remainers’ should find this a useful report, which pulls no punches in illustrating how dire the current situation is, and cogently lays out why there’s no magic bullet which would sort it out.