HSJ’s Performance Watch expert briefing is our fortnightly newsletter on the most pressing performance matters troubling system leaders. This week by deputy editor Dave West.

The planning guidance for 2020-21 could signal the beginning of two dramatic changes of direction for hospital services in England.

First, it states: “The long period of reducing the number of beds across the NHS should not be expected to continue.”

For decades the NHS has seen reductions in general and acute beds, driven by several things — more complicated than just the budget pressure and misguided assumptions about integration schemes of recent years.

Apart from a plateau in the early 2000s, the number of G&A beds open has generally gone down each year. There has been the odd blip seeing a year-on-year increase in the winter, but each summer beds have been closed again.

The mood music has changed in recent years, however. Ironically, just as sustainability and transformation plans notoriously forecast cuts in beds and nurses in late 2016, there seemed to be a final acknowledgement within government and at NHSE that, actually, capacity needed to increase.

In the last two years, demonstrating a notch up in winter bed numbers has become a must for some in NHSE/I, with a strong interest in 10 Downing Street too, and in the summer Sir Simon Stevens decided to underline the change of direction.

The main question is, can and will an upward trend in beds be maintained?

The planning guidance says, for the first time, that the current number of beds should be maintained through the summer (“at what cost to the bottom line?” some will ask).

Then NHSE will be pressing trusts to get to 92 per cent bed occupancy. Barring a miracle (or, even more unlikely, a genuine social care funding settlement), this would require a substantial increase for next winter.

Officials indicate it is, at least, a medium-term shift.

This government has stepped up the pressure to demonstrate growing NHS capacity — a pressing priority for the Johnson/Cummings Number 10, as it seeks to prove itself on the NHS to its new voters in the midlands and north of England.

NHSE in turn has been clear that achieving this will depend on sufficient funding and support for recruitment and retention efforts; and for any construction needed. Beds won’t resource themselves. Yet the government looks likely to delay deals for both education and capital until an autumn spending review, at least.

The other question is whether this acceptance of the need to open more beds is a good thing, or an admission of defeat?

Most would say it is a necessary move – and many would say well overdue. Sir Simon would cite the figures showing the UK is already near the bottom of the European league table on bed numbers, so entitled to a boost.

But there is an indisputable clinical and caring rationale that having more people in hospital is a bad thing: for helping people avoid a destabilising emergency admission or — once it happens — getting them out before they lose muscle function, independence and/or get an infection.

We do need more hospital beds based on current population trends and, crucially, on our current model of care. It is an admission of defeat, for now, though, for efforts to meaningfully change that model.

Ditching the four-hour standard?

Soon the new government will have to thrash out with NHSE its priorities for the four years until the next general election - what will it do with the remainder of the long-term plan money and whatever else can be extracted from the Treasury?

There will not be enough to deliver everything: look at the chart showing how far current spending plans lag behind the trend; and behind what the economists say is needed to deliver and modernise the service.

This gap means millions seeking mental health help continuing to go without; or crisis community services undelivered; or general practice in stasis; or keeping waiting lists growing; or — and here’s the relevant bit — little recovery of the accident and emergency target.

The choices can be made or avoided. Hence, perhaps, Sir Simon’s battle to scrap or overhaul the A&E target.

If it’s kept, the NHS may well have to throw the sink at trying to meet it — for which, of course there are very good arguments in favour — there will be other things that won’t get done.

The key line in the planning guidance on this is: “The approach to implementation for each pathway will be considered individually, any changes will be agreed with government, and further operational guidance will be published in March 2020.”

It means, “wait and see”. The final decision has not formally been made — not unwise since the clinical review has not finished. HSJ understands efforts are ongoing to get important voices and decision makers in various camps on board.

At the moment the preferred plan in NHSE, however, is that changes to the targets regime will be “phased” over the next few years, alongside a new effort to deliver NHSE’s various urgent and emergency care reforms, and a range of changes to other delivery targets.

If this does transpire, then 2020-21 will be the beginning of the biggest turning point in emergency care since the four-hour target’s introduction in 2004.