NHS may ditch four-hour target under new proposals

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NHS bosses to consult on ditching four-hour target
NHS review of clinical standards sets out five new A&E standards
Review also sets out proposals to axe the 18-week waiting standard

NHS bosses have set out controversial plans to ditch the NHS’ four-hour emergency access target despite concerns removing the uniform benchmark could lead to quality standards being watered down.

The NHS review of clinical standards, published today, confirms reports last week that ditching the health service’s main performance metric, which it has not hit since July 2015, is among the proposals which will now be consulted on.

The report also sets out proposals to axe the 18-week waiting standard for elective care, with an average waiting target introduced instead (Read more about 18 week proposals here).

The review, led by NHS England medical director Stephen Powis, sets out proposals for five new accident and emergency targets it says would improve clinical and patient priorities.

They are:

Time to initial clinical assessment in A&E to “identify life-threatening conditions faster”;
Time to emergency treatment for critically ill and injured patients (including heart attack, major trauma; sepsis, severe asthma and mental health presentation);
Mean waiting time for all patients and strengthened reporting of trolley waits;
Better utilisation of same day emergency care (also known as ambulatory care); and
New call response standards for 111 and 999 to better match patients to best services.

The review, Clinically-led review of NHS access standards: Interim report from the NHS national medical director, does not explicitly state the four-hour target would be dropped. But HSJ has been told that is the intention should the proposals get the green light following the consultation and pilot period.

A testing period for the new A&E standards will run from April 2019, a further rollout following in autumn 2019 and then full rollout from April 2020.

The proposals are hugely contentious. They come just a month after the health service slumped to its worst ever performance against the four-hour benchmark.

The Royal College of Emergency Medicine, political opponents and some patient groups have already reacted furiously to speculation the target could be dropped, accusing system leaders of planning to water down care standards.

The Royal College of Emergency Medicine’s lay chair accused NHSE chief Simon Stevens in January of being “hell bent on undermining the benefits the four-hour A&E standard has delivered to patients over many years”.

The review, however, insists the new proposals would deliver improvements to patients safety rather than watering down standards.

It says: “We believe these proposals offer improvements against all five [limitations of the existing four-hour target].”

The review says the limitations the new regime seeks to address are:

The standard does not measure mean for total waiting time;
The standard does not differentiate between severity of condition;
The current standard measures a single point in an often very complex pathway;
Hospitals’ processes, rather than clinical judgement, are resulting in admissions or discharge in the period before breach; and
The standard is not well understood by the public.

Dropping the four-hour target would mark the most significant change in the NHS’ performance regime since the standard was introduced in 2004.

Senior clinicians at the royal colleges have struggled to agree a united position on scrapping the four-hour target.

The Royal College of Emergency Medicine has been lobbying fiercely against the move, but the Royal College of Physicians and the Royal College of Surgeons are far more relaxed about a major reform, HSJ understands.

The Academy of Medical Royal Colleges, the group which represents all the colleges, told HSJ last week the four-hour standard could be retained “in conjunction” with new targets.

It has also said previously that the review is “not about relaxing or indeed even tightening current administrative targets, but about setting the right standards that are clinically most appropriate for patients”.

It added: “This must and can be done without unintended adverse consequences, and it can both sustain short waits while ensuring further gains in clinical quality.”

Cancer targets

Access targets for cancer are to focus on telling patients whether they have cancer sooner, rather than measuring the time it takes for a patient to be seen by a doctor.

Proposals for new access standards, published today, have confirmed the NHS is planning on dropping the two-week target for patients to be seen by a specialist after urgent referral by their GP. It will replace it with a four-week target for patients to know for sure if they have cancer or not.

This will mean patients must be seen by a consultant “well before the 28-day point” to make sure they get their diagnosis within time, according to the interim report on the NHS clinical director’s clinical review of access standards.

The report has proposed changes to “allow a renewed focus on diagnosis – the most crucial determinant of cancer survival – rather than interim steps along the patient pathway”.

It has suggested simplifying the 62-day and 31-day waiting targets. At present, each is subdivided by how a patient is referred into the pathway, what treatment the patient is going to receive, or what type of cancer they have.

Providers are obliged to start treating a fixed proportion of patients within the different standards, so 90 per cent of patients should enter treatment within 62 days if referred into the urgent pathway from a screening service. It is 85 per cent for those referred by a GP.

The new standards will introduce clear thresholds for each of the three new combined standards when they are implemented in April 2020.

And today, the Royal College of Surgeons and Royal College of Physicians released a joint statement expressing their support for “piloting, new NHS targets and measurements for cancer, emergency and planned treatment in England”.

The statement was issued by their respective leads Derek Alderson and Andrew Goddard, who have both been closely involved in the review.

It said: “Whilst improving patients’ access to care, the current standards have also led to some perverse behaviours. In the spirit of advancing medicine by testing hypotheses, we therefore support plans to pilot new NHS targets and measurements for cancer, emergency and planned treatment in England.

“The RCS and RCP have had constructive discussions with NHS England and other medical royal colleges about these standards. Their development must be driven by doing the best for patients, ensuring that they are seen and treated in a timely manner. And they should incentivise behaviours that lead to better treatment for patients, rather than hospital processes. It is crucial that any new standards are developed in partnership with doctors and patients.”

A RCEM statement said: “The college is still very clear that rather than scrapping the four-hour access standard, it should be supported by a series of complementary metrics that help understanding of the causes of long waits and crowding in emergency departments.”

RCEM president Dr Taj Hassan added: “While we are dismayed by many of the myths being pedalled around the four-hour standard, we are keen to ensure that any changes are not imposed due to political will but are developed responsibly, collaboratively and are based upon clinical expert consensus in the best interests of patients.”

NHS Providers also welcomed the principle of updating the targets to ensure they compliment clinical practice, but the trust lobby group warned the NHS “must guard against any sense of ’moving the goalposts’ to bring the standards back within reach”.

Deputy chief executive Saffron Cordery added: “In order to win public confidence, it will be vital to ensure this process is clinically led and that any changes have been carefully tested and evaluated.

“This is particularly important in view of the fact that performance against the current standards has slipped.

“Any roll out will need to be incremental and must have the full backing of the clinical community and leadership of NHS trusts.”

A Department of Health and Social Care statement said: ”As part of the clinical review of standards we note NHS England has today set out proposals which will be trialed in a number of areas across England.”