The clinically-led review of access standards is expected to make a number of recommendations to amend existing waiting-time targets within the NHS within the next few weeks. It is therefore a timely moment to reflect on the history and purpose of those original targets, on the broader benefits and limitations of access targets within health and care, and on the multiple functions the constitutional targets have come to serve within the NHS as it operates today.
This briefing examines the range of functions that the existing standards currently fulfil and what will be required to amend them effectively and sustainably. We hope that this briefing will also support conversations to build a broad consensus about the purpose, role and future of access standards in the NHS among those who use the current standards in their different ways – NHS leaders, frontline staff, the public, politicians and wider stakeholders.
A short history of access standards
The purpose of NHS waiting time standards is to set out the maximum amount of time people can expect to wait before they are able to access certain forms of NHS care. The NHS constitution is enshrined in law and sets out the principles and values we can all expect from the service. They also support the delivery of high-quality care in terms of patient experience and safety. The constitution should be renewed every ten years. The NHS constitution handbook provides more information about the rights and pledges staff and the public can expect from the NHS (including the current access standards) and can legally be amended by the Secretary of State without public consultation. Together, these documents provide a 'compact' between the health service and the public.
The bulk of the current access standards were introduced in the early 2000s under the Labour government in response to a very challenging performance position in which patients were waiting an exceptionally long time to access treatment.The decision was made to focus on a small number of areas that were deemed particularly important to the public and the access standards were used as a means of driving and measuring improvements in operational performance in those areas. Following significant financial investment in the NHS over the period, measuring performance against the waiting-time targets was also used to effectively demonstrate the return on the extra investment to government and taxpayers.
The constitutional standards currently cover a range of NHS access points, including urgent and emergency care services (both ambulances and A&E), diagnostic testing, planned and routine operations and cancer screening and treatment. As such, the constitutional targets are acute focused and do not include mental health or community pathways. Perhaps the most well known of the standards, often cited in political and media discourse, is the target to admit, discharge or transfer at least 95% of people within four hours of arriving in A&E. In relation to non-urgent, consultant-led care, the target is that 92% of people should receive treatment within 18 weeks. In terms of targets for cancer services, the standard is that patients should expect to begin treatment within 62 days of being referred for a suspected cancer. There have been some small alterations to some of the standards over the years with the NHS leading the way with the introduction of mental health standards, the first in the world of their kind. In the last few years, the ambulance standards have been overhauled and there are plans underway to pilot two new community response standards which currently sit outside the clinical review of standards.
The clinically-led review of NHS access standards
In 2018, Professor Stephen Powis, the NHS national medical director, was asked to carry out a clinical review of access standards across the NHS in England. The then prime minister commissioned the review to ensure that NHS performance measures reflected and encouraged latest medical practice and supported the delivery of the long term plan. In March 2019, an interim report was published which set out initial proposals to update several of the existing standards set out in the NHS constitution handbook. The review also proposes to expand the number of mental health standards so they include a broader range of services.
Rightly, the review is clinically led and sets out that any changes to the existing standards must:
- promote safety and outcomes
- drive improvements in patients' experience
- are clinically meaningful, accurate and practically achievable
- ensure the sickest and most urgent patients are given priority
- ensure patients get the right service in the right place
- are simple and easy to understand for patients and the public
- not worsen inequalities.
The proposed standards are being tested by providers across England. In January 2020, the national clinical director confirmed that testing for mental health and elective care would roll into 2020/21 and final recommendations for cancer and A&E are due this spring.
As the review progresses at pace, the potential impact these changes may have on the NHS, and on the provider sector is becoming clearer (see section 5).
The proposed changes are significant and will require changes to the NHS constitution handbook which NHS England has promised would involve public consultation. This report is intended to examine some of the arguments involved, and act as a springboard towards the consensus needed in redefining such an intrinsic element of how the NHS operates.
Successfully introducing new standards
In 2015, following a sustained campaign to move towards parity of access between mental and physical health care and in consultation with the sector, the first set of mental health access and waiting time standards were introduced. The standards were focused in three areas:
- Psychological therapies – 75% of adults referred to the improving access to psychological therapies (IAPT) programme should begin treatment within six weeks of referral and 95% of adults referred to the IAPT programme should be treated within 18 weeks of referral.
- Psychosis – at least 50% of people experiencing a first episode of psychosis should start treatment within a National Institute of Care Excellence (NICE)-recommended package of care with a specialist early intervention in psychosis service within two weeks of referral.
- Liaison psychiatry – Care Quality Commission (CQC) inspections of acute services should include a specific focus on liaison mental health services and mental health care, as well as the quality of treatment and care for physical conditions. By 2020, all acute trusts should have in place liaison mental health services for all ages appropriate to the size, acuity and specialty of the hospital.
In 2016, in line with initial ambitions to introduce access and waiting time standards across all mental health services, the government introduced waiting-time standards to improve access to eating disorders services for children and young people. By 2020/21, 95% of children and young people with an eating disorder should receive treatment within one week for urgent cases and within four weeks for routine cases.
After the largest academic study into ambulances in the world, and extensive piloting with the sector, the ambulance quality standards were updated in 2017. The ambulance response programme made changes that prioritised the sickest patients, ensuring they receive the fastest response, drove clinically and operationally efficient behaviours and put an end to unacceptably long waits by ensuring resources are distributed more equitably across all patients.
The changes were piloted with two ambulance services in England and the University of Sheffield carried out a large scale study in which over 14 million 999 calls handled with the new 999 script were reviewed over an 18-month period. The roll out of the new operational model was then staggered across different ambulance services with them now all working within the new framework.
The new standards, in the NHS handbook instruct the ambulance service to:
- respond to Category 1 calls in seven minutes on average, and respond to 90% of Category 1 calls in 15 minutes
- respond to Category 2 calls in 18 minutes on average, and respond to 90% of Category 2 calls in 40 minutes
- respond to 90% of Category 3 calls in 120 minutes
- respond to 90% of Category 4 calls in 180 minutes