• Jim Mackey says “too dangerous” to scrap four hour target completely
  • But he says he supports calls for emergency performance target reform debate
  • David Dalton also says he supports “signal” that system should openly discuss targets
  • Both warn public engagement crucial for politically sensitive target debate

Senior NHS leaders have welcomed a debate on emergency targets but warned scrapping the four hour standard completely could be “too dangerous”.

Former NHS Improvement chief Jim Mackey and Northern Care Alliance NHS Group chief Sir David Dalton both welcomed what the latter described as “the signal that we should now talk more openly” about the statutory targets.

It followed NHS England chief executive Simon Stevens’ suggestion in an exclusive HSJ interview last month that the four hour target was outdated, ahead of a review of the system’s core targets as part of the NHS’s long term funding settlement.

Mr Mackey, who oversaw a review of the emergency target while head of NHSI which was torpedoed for political reasons, said he remained “very much in favour” of investigating the reform of emergency performance measurement.

The Northumbria Healthcare Foundation Trust chief told HSJ: “The standard has been helpful, especially in the early days, and is still a good barometer of system health – a canary in the mine.”

“We must not forget how bad things were before the standard. I wouldn’t ditch [the four hour target] completely – that would be too dangerous”. But he said there would be value in “taking the opportunity to make it more clinically relevant for today [and] adaptable for the future”.

He said he still supported the concept he was trying to develop at NHSI of a metric which “looked at a broader set of issues and the whole system, for example, we really need to look properly at primary care access and its impact on emergency department attendances”.

He stressed the importance of patient safety in any reform and that double-running of any new metric might be required to ensure it was an improvement on existing arrangements.

Sir David agreed that a debate around reform of the totemic target was due. But he stressed, as did Mr Mackey, that it would be imperative to secure “public understanding and support” if there were changes.

“Review, reassessment and where appropriate, recalibration of ‘what’ we measure and ‘how’ we measure is sensible…I welcome the signal that we should now talk more openly about the standards that matter most to us – and ensure that these are always aligned to what we want to attach importance to,” he said, in response to last week’s HSJ Performance Watch on how to tackle the issue.

Mr Mackey originally announced plans in December 2016 for hospitals to be rated against a new accident and emergency standard which would combine the waiting time target with clinical standards and data on staff and patient experience.

The four hour target would remain the “headline indicator” but the new metric “will give a clearer picture of the health of our A&E departments”, he said.

But the NHSI review was aborted following then health secretary Jeremy Hunt raising the prospect of restricting the 95 per cent target for only the most urgent of cases in a parliamentary debate.

Mr Hunt’s comments provoked a public backlash and concerns that minsters want to water down the target, not hit since July 2015, to cover up performance problems and patients would be put at risk.

HSJ understands NHSI officials agreed reform would be viewed as an attempt to fiddle the figures in the circumstances, and the complexity of the task also meant a quick resolution of the issue would not be possible.

The Royal College of Emergency Medicine said it welcomed the debate, but president Taj Hassan robustly defended the existing target regime.

He said: “The four hour standard is undoubtedly one of the most resilient metrics of system performance ever devised. It’s as powerful and relevant now as it was 15 years ago. We also know system performance is proven to have a direct impact on patient safety and timely clinical care.”

“We have looked at it several times over the years, and rightly so, as it’s always good to try and improve. But while patients are certainly better streamed onto pathways now than when the four hour standards was introduced, fundamentally, the way we treat patients in emergency departments has not radically changed – clinical staff are focused on safety and timely clinical care.”