Performance Watch: The four-hour target is on life support – but not dead yet

Senior NHS England figures want to ditch the four-hour standard – but it may yet still play a role in how the NHS measures emergency performance. The onus is now on the NHS to robustly test the alternatives and establish if they are any better, writes James Illman.

NHSE should be commended for grasping the nettle on target reform. The limitations and perverse behaviours driven by the four-hour target are well documented and there is a clear case for trialling alternatives alongside the existing system.

But the manner in which the much anticipated review of the service’s core performance targets was published on Monday and the tight implementation schedule for the proposals prompted many senior NHS figures to conclude “a process is following a decision”.

The Clinically-led review of NHS access standards set out controversial proposals which could see both the NHS’ core access targets – the four-hour emergency and the 18-week standards – axed, as we reported on Monday.

It also means some major changes for mental health (see box below).

Rushing the long-awaited document out the day before one of the biggest votes in Parliament’s history, ensuring the media and politicians were distracted by Brexit, certainly looked like a cynical ploy to avoid scrutiny.

Excluding the Royal College of Emergency Medicine from the small group of external organisations invited onto the review panel also looked like an almost farcical attempt to ignore dissenting voices.

But there is some good news for those who believe scrapping the four-hour standard would be catastrophic – which of course includes RCEM and some senior NHS provider chief executives.

After months of speculation about the four-hour target’s future, the phoney war is now over and those in favour of ditching it must demonstrate the alternative models are better than the status quo. And this will not be easy.

Yes, the schedule for new targets to be fully rolled-out for April 2020 is incredibly short, arguably too short.

And, yes, it gives the impression of the higher-ups trying to bulldoze through what they think is best – and there are those within NHSE who are apparently “hell-bent” on ditching the four-hour standard.

But the testing period, for which pilot sites are currently being finalised, is also long enough that if the alternatives are not working, opponents will be able to point to firm real-world evidence of this – and then perhaps it will need to go back to something akin to a second vote.

The onus will be on NHS providers, and external oversight bodies like the health select committee and think tanks, to forensically examine the performance of the proposed alternatives and see if they really are any better than the status quo.

And if they are not, the sceptics will need to make their case as forcefully as the likes of NHSE chief executive Simon Stevens and chair David Prior have made the case for replacing the four-hour target.

The challenge of getting such reforms past Parliament must also be considered. The last effort to reform the four-hour target in 2017 was quickly gunned down after then health secretary Jeremy Hunt suggested in Parliament it could be removed for minor ailments.

Health secretary Matt Hancock, on record as being open to replacing the four-hour target, has remained uncharacteristically quiet so far. But he, and ultimately the prime minister, will need to sign this off.

One thing that is becoming clear is a growing consensus that the future targets regime cannot rely on just one headline measure. A single target is simply too vulnerable to gaming and disadvantages patients when they fall outside that standard.

The testing process will therefore be used to establish what combination of metrics will be best placed to illustrate performance.

HSJ understands that, of the five new metrics, the “mean time in A&E” is the one the review team see as the most comprehensive lead measure, albeit one which will not work without supporting metrics.

The metrics are (for full details see page 27 of the document) :

• Time to initial clinical assessment in A&E to “identify life-threatening conditions faster”;
• Time to emergency treatment for critically ill/injured patients (including heart attack, major trauma; sepsis, severe asthma and mental health presentation);
• Mean waiting time for all patients and strengthened reporting of trolley waits;
• A same-day emergency care target; and
• New call response standards for 111 and 999.

The review document does not commit to using all the new metrics, or explicitly rule out the four-hour metric in any future configuration.

And as the four-hour target data will be collected alongside the new measures, it is not inconceivable that despite the desire of so many to do away with it altogether, it could still be a contender for the new suite of metrics after all.

As I said earlier, NHSE should be commended for grasping the nettle on target reform. It could well have been easier to say major reform was politically impossible while the system is failing so miserably on both measures and propose a rearrangement of the deck chairs.

But they must now offer a fair fight in which the four-hour measure is considered as well the five new metrics, and a decision is made based on what is best for patients – even if that means keeping the four-hour standard in some form.