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

The NHS clinical review group will need to have some aces up its sleeve if it decides it is going to recommend dropping the four-hour target, because last week revealed key players in the debate remain far from convinced, writes James Illman.

Last week marked the point at which some of the big beasts in the highly politically sensitive debate around NHS England’s review of the four-hour standard got off the fence and began to firm up their position.

It was a radio interview by Matt Hancock which provided the catalyst for the most significant interventions since system leaders first set out their proposals in March 2019.

The health and social care secretary was responding to a question about whether the government should be held to account for NHS performance against its core targets in the wake of performance collapsing to a record low against the four-hour target.

He said the NHS should be “judged by the right… clinically appropriate” targets and suggested the four-hour standard was not that target. It follows comments he made last summer, when he said the four-hour measure was “old” and “inappropriate”.

Show us the evidence or we’re out

The royal colleges have always struck a pragmatic tone. They have largely acknowledged the four-hour target has flaws and welcomed a review to see if a better option could be developed, with the caveat any proposed changes would need robust clinical evidence.

Mr Hancock’s comments were widely interpreted as the health secretary pre-empting the clinical standards review team’s verdict and an attempt to smooth the way for the four-hour standard to be ditched come what may.

The Royal College of Emergency Medicine was the first to contradict the health secretary’s suggestion, as first reported by HSJ, and in unambiguous terms.

RCEM president Katherine Henderson said: “So far… we’ve seen nothing [from the standards review] to indicate that a viable replacement for the four-hour target exists and believe that testing should soon draw to a close.”

It is significant Dr Henderson thinks the trial of potential new metrics should be concluded despite it not having found any evidence of a viable replacement.

She added pertinently: “Rather than focus on ways around the target, we need to get back to the business of delivering on it.”

Shortly after the college’s statement, the British Medical Association, the Society of Acute Medicine, the Royal College of Nursing and the Patients Association all waded in, raising their own fundamental concerns about scrapping the target (see story for more on their concerns).

And then the Institute of Fiscal Studies made a highly unusual foray into NHS access targets, warning “government should think carefully” before making any changes to target.

It said there was evidence the target had saved lives.

The list of influential objectors makes ditching the target significantly harder, especially as the clinical groups’ opposition significantly undermines Mr Hancock’s argument the target should be junked on clinical grounds.

And while Mr Hancock may be enthusiastic about reforming the target, well-placed senior sources also told Performance Watch this is not yet a view shared across government. Both the Treasury and Number 10 have yet to buy into the idea, they said.

The issue is starting to cut through to the public now, making the front page of a national newspaper and even appearing on satirical news websites, something that rarely happens with NHS performance metrics.

And what do NHS managers think?

It is worth remembering the high level of support for the standard among senior NHS managers. Exclusive HSJ research in July found more than seven in 10 hospital trust board members wanted to retain the target.

Despite the significant support in their ranks for the target, both NHS Providers and NHS Confederation, much like their clinical counterparts, showed a genuine desire to explore alternative options. Neither have taken a definitive public position yet.

But privately there has been a great deal of frustration among senior NHS managers about how the trial has been conducted.

Many feel the process has been rushed, opaque and not engaged enough with the wider system. And concerns expressed to HSJ in April — that a process was following a decision — appear not to have abated.

The problems managers talk about extend far beyond the emergency department.

The target sets the ‘drumbeat’ for the whole system 

“For better or worse, the four-hour target sets the drumbeat for the whole system. Everything else runs off it, so getting rid of it would not be straightforward at all,” says King’s Fund chief analyst Siva Anandaciva, in what represents a good summary of the concerns expressed by several senior managers.

Mr Anandaciva added: “It forms the basis for other standards, like the 92 per cent bed occupancy target. It has dictated not just how services are delivered but also how they are designed, for example the creation of clinical decision units and short stay wards.

“Clinicians and managers understand how it works, so it does not surprise me to hear that some areas are thinking of keeping it locally, even if it is dropped as a national target.”

NHS Providers director of policy Miriam Deakin supported the view. She said: “It is also important not to underestimate how embedded the four-hour standard is in the system now, both as an operational and regulatory measure and as a safety measure. We mustn’t underestimate the upheaval and investment in new data and IT systems involved in amending it.”

Key questions the review would need to answer around the wider system management implications if they do recommend ditching the four-hour target would include:

  • What would the NHS use as its main proxy metric for systemwide performance if the four-hour target is ditched?
  • What would the main statistic to hold ministers and government to account be?
  • What would be the main statistic NHS leaders would use to argue for more funding from government?

If the review does decide it wants to recommend ditching the four-hour target — and that is of course still an “if” — the evidence of the last week suggests they would have a huge task to convince clinicians, managers, patient groups, and the government. The evidence the group has presented so far, for many of the key players in these groups, simply does not stack up.