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

Hospitals’ targets regime could be radically altered if new one-hour standards for “life threatening” conditions, which are being trialled this month, are rolled out nationally next year, as planned by NHS England. This week’s PW brings you up to speed on the debate going on behind closed doors and the sticking points.

When questioned on the dangers of dropping the four-hour target as part of the ongoing review of NHS standards, system leaders often couch their answer in terms of a quid pro quo.

The implicit deal is roughly this: the NHS and its patients could lose the long-standing universal four-hour backstop but gain a pledge that patients with “life threatening” conditions are seen quicker – within one hour (although the public might have assumed this would happen anyway, and emergency doctors say it already does).

And now we’re about to find out what these shorter targets could look like with the 14 trusts piloting new accident and emergency metrics as part of the NHS clinical review of standards set to begin trialling a series of new one-hour targets for a group of life threatening conditions from later this month.

When the review was published in March it named stroke; heart attack; major trauma; critically ill patients, including sepsis; acute severe asthma; and mental health presentation (which will be addressed in a later trial of new mental health targets) as the areas these new shorter targets could focus on.

The review also proposed a roll out of new standards from April 2020.

Quick refresher: where the A&E standards trial is up to

NHS England’s clinical review of standards, published in March, set out plans to trial a range of new emergency care waiting time standards.

The trial could pave the way for the abolition of the NHS’ most important performance measure, the four-hour standard.

Proposed new standards include the average (mean) time for patients waiting in A&E; time before a patient is clinically assessed; and then how long the most critically-ill patients wait (eg: stroke and heart attack patients).

The 14 trusts involved in the trial recently finished the first of two six-week testing periods. They are now awaiting further guidance on what to test in a second six-week period, in the coming weeks.

But, as I touched on in the last Performance Watch, a lively debate is ongoing around which conditions the new one-hour targets should apply to. Suffice to say the special interest groups for all manner of conditions have been pushing their case. 

Senior figures familiar with discussions told me there was a degree of consensus around the inclusion of stroke, heart attack and major trauma, albeit with a lot of details needing to be fleshed out on the latter.

There appears, however, to have been less consensus among the trial trusts and other parties on the review’s various steering groups around the critically-ill patients category and asthma.

In the lead up to the review’s publication, NHSE chief Simon Stevens and other national figures repeatedly cited sepsis alongside heart attacks and stroke as conditions which the shorter standards should focus on.

So, when HSJ revealed the sepsis metric would be subsumed into a broader physiological derangement/deteriorating patient target rather than be conditioned with a standalone target, a few eyebrows were raised.

Sepsis UK chief executive Ron Daniels told me this week the decision to drop the standalone target was “disappointing” and could lead to potential patient harm.

“Sepsis is one of the most common causes of acute physiological deterioration and I can understand the rationale for bringing it into a broader deterioration standard.

“However, we are concerned that incorporating sepsis as part of a broader deterioration standard will take the focus off sepsis. In the context of it being such a prevalent killer, we feel that has the potential to cause harm.”

Dr Daniels said he was supportive of using the national early warning score – the NEWS 2 – as a metric for deterioration. But he said the measure “does not identify patients with sepsis” and “we [the NHS] are going to take our eye off the ball”.

The move was, however, welcomed by several influential players. The Society of Acute Medicine, which previously raised concerns to HSJ that the sepsis target could encourage “bad clinical practice to beat the clock”, welcomed the move.

Other respected senior clinicians have also raised concerns about the perverse behaviours a sepsis target could drive, and that inclusion in the broader physiological derangement metric “made clinical sense”.

One senior clinician told me they were concerned “all serious illness would be treated as sepsis until proven otherwise” if a separate metric was introduced and that this will “lead to death via lack of diagnosis”.

If, as it now appears, there is no sepsis target, the review will need to make very sure its chosen method for incorporating sepsis is on a very sound clinical footing. Sepsis UK is a media savvy and politically influential lobbyer and will be there to hold it to account on its performance under any new regime.

Questions have also been raised to HSJ around the asthma target, which one well-regarded source close to the trial described as “the worst of the lot”. And they are not alone in holding that view.

“Asthma has a range from people who have forgotten their inhaler to people who need to go straight to intensive care. There is anxiety around that [trusts will start] changing the way they record asthma [if a new one-hour target is introduced],” the source said.

The common thread linking the concerns around an asthma and sepsis target is that critics are worried the new targets will unintentionally drive perverse behaviours as A&E staff scramble to ensure they don’t record too many breaches.

This has, of course, always been the principle criticism of the four-hour target.The unintended consequences of any target are often their greatest flaws.

And all the unintended consequences are rarely evident until the standard has actually been used “in the field” and possibly not completely visible until the target has been around long enough for everyone to work out the best way to game it.

The trial of the new targets and the types of behaviours, both good and bad, they drive will doubtless be fascinating.

So, it’s a shame NHSE continues to keep the experiment in a black box. The opportunity for systemwide learning from the process if it were more open would be huge.