• New metrics being trialled to replace four-hour target show “promising” results, says NHSE review
  • NHSE review’s report published alongside new poll says it shows public don’t understand four-hour target
  • Overall waits at pilots sites lengthen slightly but admissions were reduced
  • NHSE medical director insists it is “too early to draw conclusions” with final proposals not due until March

NHS England appears increasingly likely to recommend a major overhaul — and potential scrapping — of the four-hour accident and emergency target, statements issued today suggest.

A progress report by NHSE’s clinical review of standards review team said a trial of new metrics designed to “remove the four-hour cliff edge” had been “promising”. It was critical of the four-hour standard.

NHSE issued a press release this afternoon on the progress report. This also highlighted new polling on the issue, which NHSE claimed showed “people do not understand the four-hour standard”.

The standards review report also said “well-documented issues… suggest a more sensitive method of measuring the timeliness of care is needed [than the four-hour target]”.

NHSE medical director Stephen Powis, however, said it was “too early for us to draw conclusions”. And the report said “further testing over the traditionally busier winter period will help medics and other experts determine whether [the promising results so far] continue”.

NHSE said the results from the pilot study showed that while overall waits had slightly lengthened, by on average six minutes, waits for admitted patients had been shortened and the total admissions had been cut.  

But NHSE’s decision to publish the review alongside a survey which it said showed “the [four-hour] measure was not well recognised, and more people would find an average waiting time understandable and useful” appeared to indicate their preference.

The NHSE press release said: “A national survey commissioned by Healthwatch England found that an overwhelming majority of people placed a high priority on early initial assessment on arrival at A&E for everyone, allowing staff to prioritise those patients with the greatest need, and ensuring that patients with critical conditions get the right standard of care quickly.

“These priorities are mirrored in new standards now being trialled across the NHS, as part of a review led by [Professor Powis]… They include a rapid assessment measure for all patients arriving at A&E, coupled with measuring how quickly life-saving treatment — or critical time standards — is delivered.”

On the trial of the new urgent and emergency care standards, the progress report said: “We are working… to find out whether using a broader set of measures than the current four-hour threshold can better ensure those who need it get the right care fast…

“Initial results have been promising. The number of patients spending over 12 hours in A&E has fallen faster in trial sites than a control group, and there are signs that more people are getting the help they need to return home on the same day.”

The 14 pilot trusts have been trialling a suit of new indicators since the spring following the clinical review of standards interim report setting out recommendations in March.

The main one is an average (mean) time for patients waiting in A&E while others include time before a patient is clinically assessed, and how long the most critically ill patients wait (eg: stroke, heart attack and sepsis patients).

Longer waits overall but less admissions, says NHSE pilot

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 began.

But admitted waits fell by three minutes, from an average waiting time of five hours and 15 minutes, to five hours and 12 minutes

Non-admitted patients average time in the ED rose by nine minutes from three hours and one minute, to three hours and 10 minutes.

While this meant seven out of ten patients were waiting longer overall, NHSE said the study proved that “as intended, by spending slightly longer in A&E the proportion of patients who are admitted to hospital seems to have fallen”.

Nuffield Trust chief economist John Appleby: “It really is too early to tell whether these new targets might be an improvement.

“From the initial analysis of A&E data it remains unclear which people have won or lost out under this new regime.

“We really need to know this to decide whether longer waits for some are a price worth paying. Although new targets are likely to benefit some patients, so far many have been left to wait longer.”

“Therefore it’s still uncertain whether these results truly deliver what this review was looking for – to ‘lock in short waits’. We are absolutely supportive of the idea of rigorously testing new targets but NHS England need to make it clear what success would look like.”

The baseline was taken six weeks prior to field testing. Field testing took place between 22 May and 1 October.

Opposition to ditching the four-hour target has been appearing to fall away since March.

Health and social care secretary Matt Hancock’s declaration in August that the four-hour target was “old and inappropriate” represented a shift in tone after he told HSJ last November the case for change must be “watertight”.

Meanwhile, the Royal College of Emergency Medicine’s new president Katherine Henderson also told HSJ it could support replacing the four-hour target if it was satisfied a new regime would demonstrably improve patient outcomes and cut bureaucracy for staff.

This contrasted with her predecessor Taj Hassan, who warned in January that “scrapping the four-hour target will have a near catastrophic impact on patient safety”.

HSJ exclusive research in July found there was still significant opposition to scrapping the standard among senior NHS managers, with over 70 per cent of senior hospital leaders surveyed wanting to keep the target.

But neither of the sector’s major representative groups — NHS Confederation and NHS Providers — have taken a definitive stance on the proposals yet.

Professor Powis said: “While it’s still too early for us to draw conclusions, this new research, combined with early feedback from local trials, provides real encouragement that our proposals will both command the confidence of patients and the public, and support staff to provide the high quality care we all want to see.”

NHS England said of the polling: “Only 21 per cent of people said they thought they knew what the national target for A&E was, while 79 per cent said they thought they didn’t know. When asked about what would be most meaningful to them, 70 per cent of people felt an average was easy to understand, higher than any other option.”

It’s statement added: “[Pollsters] Populus surveyed 1,773 people in England between 21 to 22 October, and found that just one in seven actually know what the current target in A&E is, despite it being used for 15 years — and less than half thought that meeting the current target should be a high priority for emergency department teams.”

The review also outlined progress on efforts to investigate new cancer, elective and mental health targets. Further analysis on these aspects will follow on hsj.co.uk shortly.