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NHS England’s clinical review of standards cogently sets out the drawbacks of the four-hour accident and emergency standard. But the ‘case for the defence’, retaining the target in some form, has not been so forcefully articulated by managers despite many passionately viewing it as a force for good.

So, who will put their head above the parapet and make the case for the existing standard?

A pilot which could result in the four-hour standard, long viewed by clinicians and managers alike as the key patient safety benchmark, being ditched is rattling ahead at breakneck speed.

NHSE has selected 14 hospital trusts to test new A&E standards which could replace the four-hour target, as revealed by HSJ on Friday, with little fanfare.

They will trial four new alternative A&E metrics set out in NHSE’s clinical review of standards last month, which include mean waiting time for all patients, from May. The new standards are planned to be rolled out nationally from April 2020.

The trusts were informed via an “operational update”. There was no press release. There is no appetite at all to draw attention to this pilot project despite its huge significance in shaping what access standards patients can expect from the NHS.

Let’s be clear; this is not about making a premature judgement on the new metrics.

They could be better than the long-standing existing measure. Even the four-hour target’s most ardent supporters admit it has limitations and vulnerability to gaming (although what target hasn’t?).

It has also been in place for 15 years, in which time clinical practice and patient pathways have changed significantly. The targets must logically fit clinical practice, not the other way around.

But it will not be possible to take a reasonable judgement on the merits and drawbacks of the new standards without a transparent process, appropriate oversight and independent scrutiny.

That external oversight is even more crucial given many system leaders, including NHSE’s chair Lord Prior and chief Simon Stevens, view the four-hour target as “outdated” and appear to be determined to drive through reform come what may.

So much so, that some senior trust figures have already raised concerns this is “a process following a decision”.

HSJ understands system leaders are also very concerned the NHS has no chance within its existing resources of getting anywhere near the 95 per cent target in the foreseeable future, especially after performance plummeted to record lows this winter.

So, who will ask the tough questions and make sure the required rigour is applied?

The Royal College of Emergency Medicine will no doubt try. It was controversially excluded from the original standards review, led by NHSE medical director Stephen Powis. The decision appeared even more puzzling, or perhaps clearer, when it emerged reforming the A&E target would be the group’s main focus.

RCEM, however, announced on Friday it had finally been invited onto the overall oversight group and an “urgent and an emergency care clinical oversight group”, albeit with the direction of travel already well established, if not fully signed, sealed and delivered.

RCEM’s opposition has also been blunted by the support, albeit cautious, from the larger royal colleges, including the Royal College of Physicians and the Royal College of Surgeons. Both colleges issued carefully worded statements welcoming the standards review. And both were on the consultation group.

So, what about the political oversight? A toxic cocktail of Brexit and the general disarray both the Conservatives and Labour find themselves in means, so far at least, there hasn’t been any.

Health secretary Matt Hancock is largely focused on Brexit and establishing NHSX, the NHS’s new digital oversight body – and it would appear, a leadership bid.

Labour are yet to take a position on the debate either, despite having understandably used poor waiting times as a stick to beat the Tories each month for several years now.

The Commons health committee – headed by its indefatigable leader Sarah Wollaston, a widely respected figure across Whitehall and the NHS – has also yet to decide how much of its time it will be able to spare.

The final group is, of course, senior NHS managers themselves. Lobby group NHS Providers has warned against ”’moving the goalposts’ to bring the standards back within reach”, and insisted changes must be fully tested and evaluated. But, it has not taken a firm stance either way, for now.    

However, many trust chiefs have recently set out in robust terms why the four-hour target still matters despite its drawbacks, like this article by Sir David Dalton and Sir Jim Mackey in winter 2017.

Sir Jim warned in July scrapping the four-hour standard completely could be “too dangerous”.

It may or may not be significant that neither of their trusts, Northern Care Alliance Group and Northumbria Healthcare FT, were included as pilot sites (see list below).

Despite plenty of opposition to ditching the four-hour target being voiced privately, very few NHS managers have put their head above the parapet.

There are exceptions, like East Suffolk and North Essex FT chief Nick Hulme, who said he would retain the four-hour target locally even if it was ditched nationally, which he said would be detrimental to patients. Mr Hulme’s trust is not involved in the trial either.

NHSE told HSJ the terms of reference and process were still being finalised.

But those who want to make the case for retaining the four-hour standard in some form, even alongside new standards (and it is likely new arrangements will focus on more than one metric), really need to start making the case – and fast. And sometimes, you don’t know what you’ve got until it’s gone.

The 14 trusts trialling new A&E metrics

  • Cambridge University Hospitals
  • Chelsea and Westminster Hospital
  • Frimley Health
  • Imperial College Healthcare
  • Kettering General Hospital
  • Luton and Dunstable University Hospital
  • Mid Yorkshire Hospitals
  • North Tees and Hartlepool
  • Nottingham University Hospitals
  • Plymouth Hospital
  • Poole Hospital
  • Portsmouth Hospitals
  • Rotherham
  • West Suffolk