Clinically-led Review of NHS Access Standards

It is well documented that standards and performance targets have incentivised and encouraged improvements in care and outcomes, and provided assurance on quality and availability of care when people need it. It is also recognised that in some cases the same targets can restrict the ability to innovate or result in other unintended consequences.

The NHS Long Term Plan sets out an ambitious but practical roadmap for the future of the health service that builds on the undoubted success of the last 70 years and ensures it will continue to deliver high quality care for all over the coming decade. The Government has now confirmed the long-term funding settlement – providing the NHS with the sustainable financial basis on which to deliver the Plan.

The history of the National Health Service is one of evolution and innovation, with each generation using the latest technology and treatments to meet the changing needs of patients and the public.

NHS access standards review

With all of this in mind, the NHS National Medical Director was asked by the Prime Minister in June 2018, to review the core set of NHS access standards, in the context of the model of service described in the NHS Long Term Plan, and informed by the latest clinical and operational evidence, recommend any required updates and improvements to ensure that NHS standards:

  • 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; and
  • not worsen inequalities.

The review is being undertaken in three phases:

  1. Consider what is already known about how current targets operate and influence behaviour
  2. Map the current standards against the NHS Long Term Plan to examine how performance measures can help transform the health service and deliver better care and treatment
  3. Test and evaluate proposals to ensure that they deliver the expected change in behaviour and experience for patients prior to making final recommendations for wider implementation

To support this work a Clinical Advisory Group was established, which includes members from the Academy of Medical Royal Colleges, the Royal Colleges of Surgeons, Physicians, Nursing and Emergency Medicine, Healthwatch, and senior members of NHS England and NHS Improvement clinical teams. The group met regularly during the initial two phases of the Review and will continue to meet and input during phase three.

Interim report

The Clinically-led Review of NHS Access Standards Interim Report, published in March 2019, sets out the initial proposals for testing changes to access standards in mental health services, cancer care, elective care and urgent and emergency care.

These proposals are now being field-tested at a selection of sites across England, with the findings helping to inform any final recommendations. The latest details of this field-testing are set out below.

Six months on from the proposals being published, we published a Progress Report from the NHS Medical Director setting out how each of the proposed new standards is being tested and the early learning.

The Progress Report commits to carry on testing in all areas. While this process is ongoing, and alongside evaluation, we will continue to engage with partners and key stakeholders nationally, and through our test sites to gain expert advice and input locally.

The information we gather through field testing, and engagement will inform final recommendations from this Review, and ahead of full implementation beginning spring 2020.

Field testing

Urgent and emergency care

The following hospital trusts have worked with the NHS nationally to agree how they will safely test the urgent and emergency care proposals, and began the first phase of the trial from 22 May:

  • Cambridge University Hospitals
  • Chelsea and Westminster Hospital
  • Frimley Health
  • Imperial College Healthcare
  • Kettering General Hospital
  • Luton and Dunstable University Hospital
  • Mid Yorkshire Hospitals
  • North Tees and Hartlepool
  • Nottingham University Hospitals
  • Plymouth Hospitals
  • Poole Hospital
  • Portsmouth Hospitals
  • Rotherham
  • West Suffolk.

The first six-week phase of testing explored whether an average (mean) time in A&E could be implemented safely, and provide clinicians with a useful measure of activity and patient experience.

Findings from this phase were that the measure was introduced successfully across all sites, with no reported safety concerns linked to the testing.

The Clinical Advisory Group for this workstream, and the trusts involved, therefore support that a second phase of testing should go ahead, beginning Wednesday 31 July.

This phase includes:

  • measuring time to initial assessment;
  • collecting data to examine the feasibility of measuring how fast critically ill or injured patients arriving at A&E receive a package of tests and care developed with clinical experts, and;
  • test sites to continue monitoring average (mean) total time in department and long waits from arrival, aiming for continual improvement.

The list of critical conditions included in testing in this phase is: stroke, major trauma, heart attacks (MI – STEMI), acute physiological derangement (including sepsis), and severe asthma.

Neighbouring mental health trusts are also testing standards for urgent community mental health services that can prevent avoidable A&E attendances by providing mental health crisis care in more suitable environments where possible. When people do need to attend A&E, the trusts above will be measuring how long people who arrive at A&E experiencing a mental health crisis wait for a psychiatric assessment and, where required, a transfer to appropriate mental health care.

Routine (elective) care

The following hospital trusts have worked with the NHS nationally to agree how they will safely test the elective care proposals, and will begin the first phase of the trial from early August:

  • Barts Health
  • Calderdale and Huddersfield
  • East Lancashire Hospitals
  • Great Ormond Street Hospital for Children
  • Harrogate and District
  • Milton Keynes University Hospital
  • Northampton General Hospital
  • Surrey and Sussex Healthcare
  • Taunton and Somerset
  • The Walton Centre
  • University Hospitals Bristol
  • University Hospitals Coventry and Warwickshire

These trusts will be testing the use of an average (mean) wait measure for people on the waiting list as a potential alternative to a threshold target, currently set at 18-weeks, to see whether keeping the focus on patients at all stages of their pathway can help to reduce long waits.

They will also be helping to understand the impact of removing a third of outpatient appointments on both the current 18-week threshold or a potential mean, in order to set a more appropriate standard in the future.

Cancer

The following hospital trusts have worked with the NHS nationally to agree how they will safely test the proposed new standard for cancer diagnosis, and will begin the first phase of the trial from late August:

  • Mid Essex Hospital Services
  • Epsom and St Helier University Hospitals
  • Kingston Hospital
  • Chesterfield Royal Hospital
  • Northampton General Hospital
  • Doncaster and Bassetlaw Teaching Hospitals
  • East Lancashire Hospitals
  • Warrington and Halton Hospitals
  • Hampshire Hospitals
  • The Royal Bournemouth and Christchurch Hospitals
  • Torbay and South Devon

These trusts will be testing the use of a faster diagnosis standard for people with suspected cancer – meaning that people can expect to be told whether or not they have cancer within 28 days of an urgent referral from their GP or a cancer screening programme – instead of the current standard of seeing a specialist within 14 days, with no measurement of when someone should be told the result.

Mental health

The interim report proposes new standards across different types of mental health care, and these require different approaches to testing.

The following trusts will test different aspects of the proposed new standards for urgent and emergency mental health care:

  • Cambridgeshire and Peterborough
  • Central North West London
  • East London
  • Livewell South West
  • Northamptonshire Healthcare
  • Nottinghamshire Healthcare
  • Rotherham, Doncaster and South Humber
  • South West Yorkshire
  • Surrey and Borders, and Berkshire
  • Tees, Esk and Wear Valley
  • West London

As described above, these trusts will work with their neighbouring hospital trusts who are participating in the testing of proposed new A&E standards.

They will also help NHS leaders to better understand the impact of the new standards in the context of efforts to deliver more care quicker and closer to home.

A further 12 areas of the country are already piloting the four-week waiting time standard for children and young people’s community Mental Health Support Teams.

These are:

  • Bromley
  • Buckinghamshire
  • Camden
  • Doncaster and Rotherham
  • Gloucestershire
  • Greater Manchester
  • Haringey
  • Northumberland
  • Oxfordshire
  • South Warwickshire
  • Stoke on Trent and North Staffordshire
  • Tower Hamlets

Within a further 12 local health and care systems, new models of integrated primary and community mental health care for adults and older adults are being tested, along with four week waiting times.

These areas are:

  • Cambridgeshire and Peterborough STP
  • Cheshire and Merseyside STP
  • Frimley Health and Care ICS
  • Herefordshire and Worcestershire STP
  • Hertfordshire and West Essex STP
  • Humber, Coast and Vale Health and Care Partnership
  • Lincolnshire STP
  • North East London STP
  • North West London STP
  • Somerset STP
  • South Yorkshire and Bassetlaw ICS
  • Surrey Heartlands Health and Care Partnership

Further information is available on the Community Mental Health Services webpage.

Testing had begun in all sites by October 2019.

Evaluation and next steps

As there have been positive initial results in each of the four service areas, testing will continue across all of them. The data that this provides will continue to be monitored and analysed, alongside learning from independent research on patient experience (led by Healthwatch England) and on how staff view the current and proposed standards (led by SQW).

All of this will help inform refined proposals, which will be subject to public consultation, which we would expect to launch in early 2020. The results of that consultation, combined with further analysis and evaluation and continued input nationally from clinician and patient groups will inform a final report and set of recommendations by the end of March 2020.  If recommendations require changes to the NHS Constitution, they will be subject to further consultation.

The approach to implementation of the proposals for each pathway will therefore be considered individually, to ensure that sufficient time and consideration is given to each, and to their interplay with the ongoing review of access to general practice.

Find out more

If you have any further queries regarding the review, please contact england.reviewofstandards@nhs.net.