Welcome to HSJ’s Performance Watch expert briefing, James Illman’s fortnightly newsletter on the most pressing performance matters troubling system leaders. Contact me in confidence here.

Simon Stevens’ suggestion this week that the four hour target is outdated sets up a much needed debate on reforming the NHS’s main performance metric as part of a wider review of the system’s waiting time targets underpinning the long term funding settlement.

The wholesale shake up of ambulance response time targets introduced last year shows reforming, and even scrapping, politically sensitive targets is possible: providing the clinical evidence is robust, the ambulance changes were backed by an extensive two year study by the University of Sheffield; and patients and staff are engaged and buy into the process.

Crucially, as the extensive Ambulance Response Programme also illustrates, reforms must demonstrably prove any reform can support better patient outcomes than the existing standards.

Unless system leaders take the time to tick these boxes, any fresh attempt to reform the totemic four hour target, introduced by Labour in 2000, will most likely fail, just as numerous attempts to do so over the last decade have.

The more recent aborted attempts to reform the four hour target have all been swiftly shut down largely because scrapping a target which is not being met (the target was last hit in July 2015) is politically challenging, and a sceptical media will also assume reform will result in watering down of standards.

A case in point was The Sun’s follow up of the NHS England chief’s comments in this week’s exclusive HSJ interview under the headline “NHS England discuss plans to scrap the four-hour A&E waiting time target – which could mean a 24 hour wait for some”.

The nuance can swiftly be beaten out of the debate, and the context and the argument lost.

That said, (at least some of) the scepticism is justified. For all its obvious flaws (it’s too blunt a measure, which drives perverse incentives and some poor decisions), it has largely been viewed as a force for good, which has driven up quality and safety by leading clinicians, patients and senior NHS bosses. Many view it as the major barrier preventing a slide back to the sort of dire waiting times last seen in the bad old days of 1990s. 

So, the problem isn’t the target per se, it’s the disproportionate emphasis on it, many health leaders and think tanks have long argued.

And to its credit, NHS Improvement began work on a more granular metric in late 2016 with the aim of addressing the four hour target’s lack of sophistication and to incentivise the treatment of the sickest patients first.

But Jeremy Hunt’s suggestion in Parliament in January 2017 that the four hour target should not apply to less urgent cases provoked a barrage of negative headlines stating he was planning to scrap the target and this would mean patients waiting longer risking their safety.

The then health secretary furiously backtracked and the focus for trusts – driven by financial incentives set by the centre – has remained squarely on meeting the four hour target.

But with the number of clinical and urgent care pathways proliferating, and fundamental questions surrounding the existing data collection system after major problems last winter, surely now is the time to bring the nearly 20 year old target regime up to date with clinical practice.

This does not mean scrapping the four hour target – or certainly not until there is robust clinically evidenced proof that whatever replaces it, or is used alongside it, is driving better quality and performance outcomes than the existing arrangements.

It means developing a new overall measure for the system, which is given the required prominence by ministers and financial incentives by central leaders that will persuade trusts to view it as a genuine priority (there is after all no shortage of data collected on accident and emergency performance).

As respected emergency care expert Matthew Cooke notes, any new system could be double run with the existing framework for several years to ensure its robustness – much like the extensive pilot done as part of the Ambulance Response Programme.

The University of Warwick professor said: “A transparent approach to developing any new measures is vital. Double running the systems would allow comparison with the old standard, and the ability to iron out any issues, which are inevitable with such a complex measure.”

“Performance data collection technology has also moved on a lot since 2000 but we are not making the most of it. A lot of the data required for a new metric can be automated, so it won’t create an additional reporting burden.”

“The four hour target has been largely successful. But when it was introduced it was a universal target covering all A&E admissions. So many patients are now streamed off into ambulatory care, to GPs, or on other pathways, that it is now relevant for an ever decreasing group.

“Developing a new measure, which could take into account factors, such as the acuity of patients, and metrics like the ‘accumulated time’ measure being used by the Getting It Right First Time programme, which I think is really good, could give us a far more sophisticated standard on which to benchmark A&E performance.”

There have been many half finished conversations about the four hour target. Whatever the outcome, it is certainly time to at least have a full conversation about the options and bring the target regime up to date with clinical practice.