• New Royal College of Emergency Medicine president open to axing four-hour target
  • But only if new regime demonstrably improves patient outcomes and cuts bureaucracy
  • Previous president said scrapping target would “have near catastrophic impact on patient safety”

The Royal College of Emergency Medicine could support replacing the four-hour target – but only if it was satisfied a replacement regime would demonstrably improve patient outcomes and cut bureaucracy for staff.

The college’s new president Katherine Henderson set out her views on the controversial issue to HSJ for the first time since taking over the college presidency this month. NHS England is currently trialling alternative metrics which could replace the four-hour target from as early as next year.

The NHS has not hit the current target – to see 95 per cent of patients within four hours – since July 2015. 

Dr Henderson indicated the college would demand a robust evidence base for it to consider supporting plans to ditch the target, but her stance notably contrasts with that of her predecessor, Taj Hassan.

Dr Henderson, who is also a well-regarded consultant at St Thomas’ Hospital, said the college would “continue to advocate the four-hour standard for the majority unless there is good evidence of patient benefit from any change”.

She added: “The standard should only be replaced by something that maintains the benefits it has delivered, whilst improving on its failings. In particular, any new metric should reduce the bureaucracy the current performance regime has created.”

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

Dr Hassan softened his stance a little towards the end of his tenure, but the change in leadership appears to have further shifted the college’s position.

RCEM has long argued prior to Dr Henderson’s appointment that the target protects patient outcomes.

Previous attempts to reform the four-hour target, including under previous health secretary Jeremy Hunt, have been met with significant opposition from politicians, emergency clinicians, NHS managers and patients.

But there are signs that, should the current review led by NHSE medical director Steve Powis, recommend axing the long-standing performance target, it may be able to win over previously sceptical groups.

News of RCEM’s nuanced but softened stance followed Matt Hancock’s declaration in August that the four-hour target was “old and inappropriate”. This also represented a shift in tone from when he told HSJ last November the case for change must be “watertight”.

Analysis: A significant moment in the four-hour target debate

The Royal College of Emergency Medicine has far from given system leaders the green light to ditch the four-hour target, but pro-reformers will view Dr Henderson’s statement as a significant move.

The Clinical Standards Review has not concluded its pilot of potential replacement metrics, and not officially recommended the four-hour standard should be dropped.

But, should this happen, as is widely expected, system leaders will need to have nailed down the support of the royal colleges if they are to stand a chance of selling it to politicians and the public.

And RCEM has, understandably, always represented the most resistant of the colleges to efforts to ditch the four-hour target. The powerful Royal College of Physicians and Royal College of Surgeons have both privately been understood to be in favour of a major reform of the target.

Imagine this possible scenario: NHS England announces plans to axe the four-hour target – one of few NHS targets with any public traction – only for the country’s most trusted senior emergency medics to raise fundamental objections and patient safety fears.

This would not play well in the media. But if RCEM backs the plans, and other groups such as patient groups and politicians follow suit, plans to ditch a target the NHS has not hit for over four years become increasingly sellable.

But what about the NHS managers? HSJ’s exclusive research in July found there was still significant opposition to such a move among senior NHS managers, with over 70 per cent of senior hospital leaders surveyed wanting to keep the target.

But neither of the key managerial lobby groups, NHS Providers and NHS Confederation, have come out either in support or against. One would, however, imagine that if emergency medics buy into the plans, this in itself could influence how other groups, including managers, view any potential reforms.

It is understandable the groups want to see what the plans are before they either back or oppose them. But if they do want to voice objections, they will need to act as soon as the lay of the land becomes apparent. 

Dr Henderson set out her priorities for reform as addressing overcrowding and patients being treated in corridors in emergency departments.

She said: “The overall system is under huge pressure and patients are being failed.

“Patients needing admission to hospital end up staying too long in emergency departments, which are becoming more and more crowded. Patients end up being moved out of cubicles and into the corridor so that departments can continue to function.”

She continued: “The official figure of 12-hour decision to admit breaches significantly misrepresents the number of patients staying more than 12 hours. This is wrong.

“We need to draw a line under the unintended consequences of the DTA process measurement point and sort out the ED crowding damaging our ability to care for patients.”

The news comes as four-hour performance figures for September reveal a further significant deterioration. Last month, 85.4 per cent of patients were seen within four hours, compared to 89.1 per cent in September 2018.


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