Performance Watch: What will be the new P45 target?

NHS England is in the process of drawing up a set of guidelines for the 14 trusts trialling the controversial new accident and emergency standard proposals in a quick-fire pilot due to begin this month.

The trial represents the foundations on which NHSE will potentially build the case for one of the biggest NHS policy changes since the 2012 reforms: the scrapping of the four-hour A&E target.

HSJ understands the trail will be carried out either in two six-week stints or over a six to eight-week period. It will investigate the use of three new indicators, the main one being an average (mean) time for patients waiting in A&E. The other two are: time before a patient is clinically assessed; and how long the most critically ill patients wait (eg: stroke, heart attack and sepsis patients).

The review’s ambitious  self-imposed timetable sets a target for a national roll-out of new proposals by April 2020.

How to avoid the sack?

The most significant question is how the pilot will evaluate whether a new regime is delivering better patient outcomes. But some senior NHS managers are – at least privately – posing another question: “If the four-hour target goes, what measure do you concentrate on to avoid getting the sack?”

Not for nothing was the four hour standard known as ‘the P45 target’ - keeping waiting times low in A&E remains the most effective lever that the service can pull to influence public opinon about its performance (and that of the government charged with its stewardship).  

Of course, tongues are planted in cheeks – patient safety will always come first. But it’s a pertinent question to consider as the behaviours, perverse or otherwise, driven by the answer will have a profound impact on how emergency care patients are treated.

Siva Anandaciva, a long-standing expert on the four-hour standard and now chief analyst at The King’s Fund, said: “I am nervous the system could end up swapping one dominant measure for another, possibly an average time in A&E, which would leave the system facing similar problems that it does now.

“The ultimate judgement must be whether patients are better off. But senior managers will ask themselves, ‘what will I get sacked for? Again, if performance against the average target simply replaces the four-hour target as it is now, then that will also potentially drive unhelpful behaviours.”

Likewise, if financial incentives or penalties are based on average waiting time, then that is what trusts will focus on, he added.

But, of course, the ultimate issue on which the reforms will live or die is whether they help deliver better clinical outcomes than the four-hour standard.

I’m told establishing a robust process to evaluate this is a major issue for the review team. Nuffield Trust chief economist John Appleby warns this will be incredibly tricky, not least because many clinical outcome measures would take far longer to analyse than the pilot’s six to eight week timetable.

Unpalatable trade-offs

Mr Appleby also points out the moral dilemmas which need confronting: “If some patients are seen quicker [under a new standards regime] and others less quickly, which is likely, this raises interesting questions about what trade-offs are the least unpalatable.”

He added: “They also need to decide what the actual target is. They have set out a basket of indicators they want to investigate but they have not said what the target [against those indicators] would be.”

There is also wide consensus that whatever the methodology, the findings will need robust and independent evaluation.

The Royal College of Emergency Medicine, which was not included on the original panel which developed the interim proposals following a series of disagreements with NHSE but has been recently brought on board, echoed this call.

The college’s president Taj Hassan said while the college viewed the four-hour target as the best measure the NHS has of A&E and system wide flow, “we do need to address some of its limitations and where it is being gamed”.

Pathology or physiology-based quality indicators?

The college raised concerns about piloting the metrics in summer, when the winter is always far busier. But its major differences with the direction of travel largely centre on the debate around “pathology versus physiology-based quality indicators”.

Dr Hassan explained: “The review wants to measure stroke, heart attacks and major trauma. We say we already do this.

“Patients don’t arrive with diagnoses, they arrive with presentations. Then we triage according to their presentations, that is their clinical needs based on acuity and how sick they look… and that won’t change.

“People with chest pains, low blood pressure, high heart rates, high respiratory rates [already] get prioritised and none of that will change. That’s why we don’t believe in focus on stroke and heart attacks because that’s not how we prioritise care assessments.”

The guidance itself, which is due this month, will not resolve all these questions. But it will be another cornerstone of the review, which must address all these issues if any recommendations for reform are to stand a chance of becoming policy.