Existing access standards currently fulfil a number of different functions. In the areas where they exist, they play a key role in the provision of effective, quality care, and in regulation, performance management and oversight, as well as in planning, prioritisation and resource allocation. The standards also enable tax payers to hold both the government and NHS leaders to account for the performance of a publicly-funded service.
It is important that when we think about access standards, we take full account of each of these different purposes which we explore in more detail below.
Service level clinical – for clinicians and patients
Informed by clinical practice, the standards act as an expression of the responsiveness of the care and patient experience the NHS should be providing. Most of the standards have traditionally been widely regarded as a good proxy for the quality and safety of care (as far as possible within the constraints of a single measure). There is a danger, however, as we have found with the previous ambulance standards, that standards become outdated, particularly as clinical practice develops over time.
Service level operational – for clinicians and service managers
The delivery of consistently excellent frontline care requires the highly complex marshalling of a number of different elements – such as making best use of skills of a wide range of different staff, using physical and technological infrastructure/resources to best effect and structuring patient journey and flow in the best way possible.
Most trusts now use the standards as the key organising principle of service provision. The relevant standard for the service is embedded right at the heart of how providers operate, including in IT systems, how rotas are planned, how staff are deployed, how physical space (e.g. an emergency department) is used and laid out and providing frontline staff and trust leaders with daily, weekly and monthly performance management information that is critical for planning and providing services.
Trust level planning, performance measurement and governance – for trust senior leaders and boards
Having these clear metrics helps inform oversight and assurance mechanisms, which give trust boards evidence and insight into the quality and responsiveness of the care they provide. They act as a crucial suite of measures, to guide longer term and annual planning, prioritisation, staffing decisions and resource allocation. Traditionally, they have provided the foundation for how the acute and ambulance sectors have structured service delivery.
Trust, system and regional level oversight, support and regulation – for the arm's-length bodies
Access standards are a means of measuring NHS system-level performance in a near real time, which assists the arm’s-length bodies in:
- supporting decisions on resource allocation and the identification of trusts needing support e.g. in identifying which trusts require additional support in their winter planning
- identifying trusts that need support in making quality of care and patient experience improvements
- providing an important element of the regulatory and system oversight framework.
National system level oversight and accountability – for the public, politicians and the media
The standards are a well established part of the 'compact' between the public who fund the service and the NHS. As a constituent part of the accountability framework between the public and the NHS, the public and politicians, and the government and the NHS, the standards provide:
- transparency of performance, enabling frequent and robust public, media and political scrutiny
- an accessible, understandable measure providing the public with the means to see what taxes are paying for
- a means of enabling the NHS to demonstrate over time that it is providing a return on extra investment (and often a means to evidence increases in demand and the need for additional investment)
- an instrument for the public and stakeholders to monitor the quality of care in their local services and to scrutinise the spending and promised improvements in the NHS – particularly where political promises have been made
- data which tracks NHS performance over time, enabling both local and national trend analysis, international benchmarking and benchmarking across the four nations in the UK which use broadly similar performance metrics.
Overall, the mechanism of having clear and easy to understand measures allows the public a clear and demonstrable means to hold politicians to account on manifesto commitments and policy changes. Importantly, the standards also act as a means for politicians and parliament to hold the NHS to account for the delivery of a key public service that accounts for 14.5% of all public spending.
The pros and cons of access standards
Over the past twenty years, waiting-time standards have become a central pillar in how the health service is organised, managed, overseen, and held to account. In the words of The Health Foundation: "NHS waiting-time performance has dominated public and political debate since the late 1990s". The move to monitoring and measuring NHS activity in this way has been mostly positive for the service and patients. There are of course pros and cons to any set of standards and how it operates in practice.
For years, the standards have played an important role as effective, understandable, proxies for the level of care the NHS should be providing. They correctly measured some key things patients consider important including how long people can expect to wait before being seen in A&E or for a routine operation. There were huge improvements in waiting times during the 2000s and the public and politicians saw a clear, tangible, measurable return on the extra financial investment made over the decade.
The link between performance against the standards, perceptions of overall NHS success, and NHS funding has also continued more recently. The continued decline in NHS performance against the standards, despite the NHS treating record numbers of patients, has been a key plank of the argument made by those calling for additional NHS funding.
Over the past decade, the access standards have been largely supported by clinicians. The royal colleges, for example, have consistently argued that standards have helped bring appropriate focus to their area (e.g. helping facilitate whole hospital mobilisation at times of extreme pressure in emergency departments or reducing the number of people waiting over a year for an operation).
Operationally, access standards have also given NHS leaders clarity on where to focus resources and prioritise, bringing a unifying purpose across a complex range of resources, activities and processes. These organising principles have worked effectively in terms of managing staff, infrastructure and resources for the last twenty years.
Lastly, as a key component of regulatory and oversight mechanisms, having clear performance metrics has helped contribute to the positive shift in quality improvement across the sector. As a result, the access standards have been an important element in driving significant and important performance improvement – it is motivational for staff and trust leaders to see and be able to demonstrate service improvements.
However, from a clinical perspective, there is a strong argument that some of the standards no longer reflect modern clinical practice. A key example is in the case of urgent and emergency care. We know that in emergency care, the way care is provided has changed with significant growth in same-day emergency care. NHS 111, urgent treatment centres and A&E front door GP triaging have removed lower acuity patients from A&E departments, which would have typically been counted within the four-hour standard. Trusts have been left with more complex presentations which take longer to assess and performance against the four-hour target will inevitably be worse. This is the case even though the treatment provided to those patients attending may be just as good as it has been in the past, potentially even better.
The current standards may mean that the right data that accurately reflects all trust activity on a particular pathway is not collected. It is important to ensure activity is captured correctly so trusts can be paid fairly for what they are doing and their performance is judged fairly and accurately.
There is a danger with all standards that the focus on particular targets may distort clinical priorities. For example, mental health trusts increasingly tell us that sector investment has simply followed the standards, and that we are in danger, for example, of prioritising improving access to psychological therapies at the expense of provision for those with more severe and enduring mental health conditions.
As with all standards or targets, there is a danger of creating waiting-list cliff edges, where trusts manage and provide care to meet the standard as opposed to what is best for the patient. For example, we know there is a spike in emergency admissions just before the four-hour mark in A&E to enable clinicians more time to make the decisions they need which also 'stops the four-hour clock' for the patient concerned. In reality, some patients may not need to be admitted, instead requiring a more straightforward intervention which can be given on the day.
Many also suggest that waiting-time standards reduce something that is inherently complex to potentially unhelpful simplicity – for example:
- there have been occasions when performance at 0.1% above standard is seen as good and 0.1% below standard as bad when the difference between the two are essentially the same in terms of performance
- when performance against standard has been regarded as the sole responsibility of a trust when it is often a function of local or national system conditions.
Under the umbrella of the NHS long term plan, the NHS is adopting a much more integrated approach to the provision of care. However, the current measures do not reflect local system performance, out-of-hospital care or the full breadth of mental health provision. There is a danger of being locked into an outdated, acute hospital centric view of what services the NHS should be providing. We also want standards which drive the right incentives and behaviours for an integrated approach.
From an operational management perspective, the current standards are at risk of offering a very narrow definition of NHS performance – so the way trust leaders and managers organise services are tightly focused on a small basket of acute hospital dominated measures.
There is a danger that this focus has driven a culture focused on delivering narrowly defined targets as the key task for the NHS frontline, opposed to a much broader set of objectives, such as delivering excellent care, driving patient-centred improvement and empowering and engaging staff.
There is also concern that the standards drive particular types of top-down performance management behaviour. The interim people plan explicitly points to the need to move away from this top down, target-driven culture to a culture based on improvement, learning, support and staff empowerment.
The standards offer a narrow definition of NHS success and fail to take into account the broader context (see section 5), which is not necessarily helpful in providing the full picture to the public or politicians.
The standards were positive in driving and showing return on investment at a time when investment in public services was increasing and in the absence of the critical workforce pressures seen today. But there is a danger that during the longest and deepest financial squeeze in NHS history and workforce shortages, that any standards drive an excessively negative view of NHS performance. Despite the fact that the NHS is treating more patients than ever before, and staff are working harder than ever, the prevailing NHS narrative is often one of the NHS failing to meet constitutional standards. This risks having a negative and demotivating impact on NHS staff and eroding public faith in the health and care model.