Performance Watch: Stevens in firing line as A&E debate heats up

Simon Stevens’ comments about the four-hour target this week provoked a furious reaction from senior emergency medics, who have demanded answers on who exactly is being consulted with by the NHS targets review.

The NHS England chief executive’s comments at the Parliamentary health committee on Monday prompted widespread national media reports, from titles including The Sun and The Guardian, that the target review is set to recommend the service’s most important standard should be scrapped.

This conclusion is premature. There is still some way to go on the review, which is due to announce recommendations in March.

But the NHS England chief’s comments certainly underlined his desire for significant changes to the target, which he branded “outdated” following the prime minister announcing plans for a review of all targets last summer.

The response, meanwhile, laid bare both the huge opposition he faces in doing so and the frustration provoked by a process which appears to be taking place in a back room somewhere in Skipton House.

Mr Stevens told the committee the four-hour target was an “administrative” metric – a loaded term in this context, given many clinicians stress its importance as a quality measure.

He said: “What [NHSE medical director and review lead] Stephen Powis is telling us is that we need to reflect changes in clinical practice.

“And since those administrative targets were promulgated, in some cases 15 years ago, actually, the practice of medicine in relation to sepsis, stroke, heart attacks has changed, which means a golden hour of focus is required on them, instead of an averaging out of a four-hour experience for a whole variety of patients.”

Context is key. The comments followed HSJ reporting last month that the review had already discussed removing the four-hour target for minor ailments and Mr Stevens’ previous assertion that the four-hour target “does not distinguish between turning up to A&E with a strained finger and turning up with a heart attack”.

The Royal College of Emergency Medicine, already frustrated because it says it has not been consulted by the NHS targets review (exclusively revealed by HSJ this month), unleashed its strongest criticism to date.

In an open letter to Mr Stevens, the college’s lay group chair Derek Prentice accused the NHSE boss being “hell bent on undermining the benefits that the four-hour A&E standard has delivered to patients over many years”.

The letter added: “The public has a right to know who these individuals are who want the target removed, not least given that in the NHS plan with many laudable objectives, this attack on the patient interest stands out alone as the only cut in services proposed.

“So Mr Stevens, who are these doctors with such contempt for the patient interest?”

The arguments Mr Stevens made this week were consistent with the position he has held since the review was first announced last June, when he told HSJ the target was outdated.

But the official confirmation that Professor Powis is pushing for reform on the target is a further indicator of the amount of zeal at the top of NHSE.

Professor Powis is a physician, but HSJ understands several other big beasts within the NHSE’s clinical ranks, like head of acute care Keith Willett, are also in favour of significant changes to the four-hour target.

RCEM will hope its former president Cliff Mann, now NHSE’s lead urgent and emergency clinical lead, will fight their corner, although he is yet to publicly nail his colours to the mast.

Another important player yet to publicly show their hand is Dr Mann’s managerial counterpart, NHSE’s urgent and emergency care lead Pauline Philip.

NHS England said in a statement that it was working with the “Academy of Medical Royal Colleges, Healthwatch England and others on what matters most to patients” and that it wanted “a wide range of views”. HSJ has requested a full list of everyone who has been consulted as part of the process so far.

Professor Powis’s statement added: “Any recommended changes will be carefully field tested across the NHS, before they are implemented…we want to hear a wide range of views, because all staff involved in the delivery of urgent and emergency care will have important insights to contribute.”

It’s also important to note in what is a highly complex debate that even the college would concede the four-hour target is far from perfect and creates perverse incentives.

But it has long viewed it as a core patient safety measure and that scrapping this backstop would spark an inevitable slide back to the kind of waiting times not seen since the 1990s.

Moreover, it sees the idea of scrapping it for minor ailments as a non-starter. It argues what can be quickly diagnosed as minor can often turn out to be more serious – or ultimately fatal – with sepsis perhaps the best illustration of this argument.

Much like sepsis, unravelling the four-hour target for minors is a far more complicated job than it might first appear – and errors in doing so will have tragic consequences.

The college’s fears about scrapping the target completely are shared by some of the big beasts of NHS management.

Former NHS Improvement chief Jim Mackey – who himself oversaw an aborted attempt to reform emergency performance management during his NHSI tenure – told HSJ in June it would be “too dangerous” to remove the standard altogether.

It is too early to judge the review group’s proposals – they simply do not exist. But such an important process should not be shrouded in secrecy, as it has been so far.

System leaders will need clinical buy-in whatever the recommendations. Running the process in this manner risks further damaging an already sensitive relationship, which will ultimately be to the detriment of the service and to patient safety.   

UPDATED: This story was updated on  30 January at 3pm to include Professor Powis’s statement from NHS England.