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A major review could be set to make significant changes in how it plans to design a new A&E performance metric which could replace the four-hour target. But fundamental questions remain around what the key evaluation criteria for new metrics are, the lack of time built in for genuine consultation, and a lack of transparency around the fast-track process, writes James Illman.

A progress report by the clinical review of standards published last week suggests it is increasingly likely to recommend a major overhaul — and potential scrapping — of the four-hour accident and emergency target, as we reported last week.

The report by a group of senior clinicians convened by NHS England said a trial of new A&E metrics designed to “remove the four-hour cliff edge” had been “promising”. It continued to highlight the shortcomings of the four-hour standard.

But the report raised more questions than answers. It also indicated a potentially significant shift in how the review thinks it can use the average time in A&E metric.

A mean-ingful metric?

The average (mean) time all patients, admitted or not, spend in A&E has been the main metric tested by pilots so far. Other targets including how long patients wait to be clinically assessed and how long the most critically ill patients wait are in the mix. But mean time it is seen as potentially the most important of the trial metrics.

The report said overall waiting times for all patients at pilot site emergency departments under the new standards were six minutes longer than a baseline taken prior to field testing.

But the authors argued while overall waits were slightly longer (roughly seven in ten patients were facing longer waits), there had been less admissions, and admitted patients’ waiting times had fallen by three minutes (to five hours and twelve minutes) following the removal of the four-hour “cliff edge”. See our news report for further details.

And in what could represent a significant shift by the review team, the report tacitly admitted the focus on all patients’ overall mean time in department could need changing.

It says: “[NHSE/I] has [also] been exploring the value of monitoring the average time in department for admitted and non-admitted patients separately, instead of having one aggregate mean covering both groups.

“This is because patients may be prepared to accept a slightly longer wait if they are able to go home, but it is still clinically appropriate for hospitals to do what they can to reduce the time that patients spend in A&E before being admitted.”

This could lead to a significant change in how any new metrics are configured.

Senior emergency medics have long warned it is hard to extract meaning from an aggregated mean time, mainly because it penalises departments which, for no fault of their own, have high admission rates.

The proportion of admissions varies hugely between hospitals, with some admitting under 20 per cent of attendances, while others admit over 40 per cent. Admitted patients normally take longer to deal with so the higher the proportion of admissions, the higher the mean time.

So, if the group does decide an aggregated mean time should be separated into admitted and non-admitted waiting times, this would certainly be an improvement.

Flaws in the process

The progress report however does nothing to allay the long-standing fundamental questions around the process.

Namely, lack of transparency, time for meaningful consultation, and the continuing sense that the whole project has been a “process following a decision”, a concern reported by HSJ back in March.

Nuffield Trust chief economist John Appleby told me it was too early to tell whether these new targets would be an improvement but that “in many ways the progress report raises as many questions as it does answers”.

He said: “The central problem is that if you have some people being better off and some people being worse off under a new system, which the data so far suggests, how do you reach a decision about whether it’s a good idea to change the system?

“They have never really set out what the criteria is they will use to make that decision.”

They may have not set this out because, perhaps, they don’t yet know what it is themselves.

But a more transparent process and allowing respected experts like the leading health think-tanks a chance to interrogate the data would perhaps help build broader trust and system buy-in to a process which has taken place almost entirely behind closed doors.

Mr Appleby also raised the issue which has become an elephant in the room for NHSE.

“The thing that is really motivating a desire to change things is the fundamental fact that so few places are hitting the four-hour target anymore. Maybe we should be asking why that is rather than looking to change the targets,” he said.

The official line from NHSE is of course that the “old” four-hour target needs reform because much has changed in terms of clinical pathways since its introduction in 2004, and not because it has not been met since July 2015.

But the nagging sense that system leaders’ desire to replace the target is driven more or as much by the fact it can no longer be met, rather than sound clinical reasons remains.

Meaningful Consultation

Then there is the issue of consultation. NHSE has pledged to consult, but it wants to do this before it publishes its final recommendations in March. This feels like putting the cart before the horse.

For the emergency care elements at least, it wants to roll out any new arrangements from April, which effectively means whatever gets announced in March is policy rather than “recommendations”.

The progress report says on page 5 that it will consult in early 2020 and the findings will inform final recommendations by March 2020. It adds that: “If recommendations require changes to the NHS Constitution, they will be subject to further consultation.”

This line is significant because the Department of Health and Social Care has already stated that access standards sit outside the constitution.

The DHSC told the Public Accounts Committee: “The waiting times standards were included in the handbook to the NHS Constitution rather than the NHS Constitution itself so, in practice, there was no legal requirement for it to consult about changes to the waiting times if the NHS Constitution remained the same.

But it added: “Regardless of the legal position, [it would be] holding a public consultation if any changes to waiting time standards were proposed as part of its ongoing review.”

NHSE’s desire to consult before publishing final recommendations and the department’s ‘we’ll consult, but we don’t really need to’ opinion don’t suggest a robust consultation process, given the huge implications of changing the NHS’s most important performance target.

HSJ has long warned that the breakneck speed of the process leaves little space for a wider debate around the review. But the lack of transparency around its findings and evaluation criteria would be easily remedied if the review group was more forthcoming.