John Kell
Head of Policy

Introduction

NHS England is developing plans to revise the access standards – more commonly referred to as targets – that it sets for key parts of the NHS. These cover mental health, cancer, urgent treatment (essentially Accident and Emergency departments in hospitals) and planned treatment (often meaning ‘elective’, non-emergency surgery).

In our initial response to the proposals our Chief Executive, Rachel Power, said:

"The findings from our recent survey on NHS waiting times suggests that, on balance, patients would be open to more sophisticated targets, including the possibility that people with less urgent needs may have to wait longer if that means the more seriously ill get faster treatment. Patient experience and outcome has to be at the heart of any changes, and it is essential that patients' views are listened to and acted on through genuine consultation before any change to what the NHS provides, including to performance standards."

This post summarises the proposals, and gives some further analysis. This includes conclusions from the survey we mentioned in our response, the full results of which can be read in this report.

The Patients Association is now sitting on NHs England’s Clinical Oversight Group for this work, and we will be feeding in the patient perspective in line with the views set out here.

Survey findings

Our survey was conducted before NHS England announced its proposals, and reached some tentative conclusions. We recommend that NHS England should explore the themes it raises further as they pilot their proposals.

Above all, the question of whether targets should be changed proved divisive among our respondents. There was, on balance, some support for changes along the lines currently proposed by NHS England, but this varied depending on the target in question, and opinions were strongly held in both directions.

Overall, targets are generally well liked and well supported by patients and the public. People who can be identified as patients or carers, rather than members of the public, are slightly but consistently more supportive of targets, and more cautious about change.

The new standards, in summary

NHS England is planning to run pilot exercises to investigate the effects that the new standards have on NHS performance in practice. The standards below are therefore not confirmed for roll-out across the NHS – not yet, anyway. Some will also require further work, for instance to identify what proportion of people should be treated in the timescale or manner described for the NHS to be said to be doing a good job.

Mental health

1. Expert assessment within hours for emergency referrals; and within 24 hours for urgent referrals in community mental health crisis services
2. Access within one hour of referral to liaison psychiatry services and children and young people’s equivalent in A&E departments
3. Four-week waiting times for children and young people who need specialist mental health services
4. Four-week waiting times for adult and older adult community mental health teams.

Cancer

1. Faster Diagnosis Standard: maximum 28 day wait to communication of definitive cancer / not cancer diagnosis for patients referred urgently (including those with breast symptoms) and from NHS cancer screening
2. Maximum two-month (62-day) wait to first treatment from urgent GP referral (including for breast symptoms) and NHS cancer screening
3. Maximum one-month (31-day) wait from decision to treat to any cancer treatment for all cancer patients.

Urgent and Emergency Care (A&E)

1. Time to initial clinical assessment in Emergency Departments and Urgent Treatment Centres (type 1 and 3 A&E departments)
2. Time to emergency treatment for critically ill and injured patients
3. Time in A&E (all A&E departments and mental health equivalents)
4. Utilisation of Same Day Emergency Care
5. Call response standards for 111 and 999.

Elective care

1. Maximum wait of six weeks from referral to test, for diagnostic tests
2. Defined number of maximum weeks wait for incomplete pathways, with a percentage threshold, OR average wait target for incomplete pathways
3. 26-week patient choice offer.

Note that these new measures will replace the existing four-hour A&E target and 18 week target for elective treatment, rather than adding to them.

Analysis

Our view is that more sophisticated measures are acceptable, provided they drive improvements in patient care. The big question is whether these changes will achieve that.

There is a significant risk of unintended consequences. For instance, could attaching a lower priority to less urgent cases in A&E just gum up A&E departments, rather than keeping a steady flow through them, given that these cases actually make up the bulk of what happens in A&E? Again in A&E, do the changes take into account the relationship between A&E and the rest of the hospital, such as flows of patients admitted into beds? Could they end up generating problems for other hospital departments, rather than driving improvements?

We also wonder whether it is necessary to ditch all the existing targets as well as introducing new measures. We note that the Royal College of Emergency Medicine supports continued use of 4-hour target, and the previous effort to develop new standards for A&E (abandoned by the Coalition Government in 2011 before it could be introduced) created measures in addition to the four hour target, not instead of it.

The feedback we have heard from patients is too equivocal to provide a justification for ditching existing measures wholesale: they enjoy strong levels of support. We must also observe that the NHS has met the four hour standard in the past – moving away from it risks simply accepting lower standards for no good reason. If NHS England could process some of its historical data against the proposed new measures, to give us a baseline against which we can assess the NHS’s current performance, that might provide some reassurance that the target is not simply being dropped to avoid the NHS having to admit it can’t meet it.

Elsewhere, the thresholds that are introduced for determining what level of performance is acceptable will be crucial. The wider range of proposed measures in respect of mental health in particular is welcome, though the NHS has a long way to go to deliver mental health services that are as good as it is now widely recognised they should be: when calls to our helpline are broken down by disease area, mental health is comfortably the largest category – and often those calls relate to complaints or grievances when something has gone wrong.

Careful assessment of the impact on patients of the changes as they are piloted will also be essential in order for them to enjoy our support.