This further decline in performance happened in a year when the NHS was trying to “do it all”; keep a firm grip on finances while maintaining performance against key access targets and developing new models of care. Performance also deteriorated despite a year of relative plenty for NHS funding, as funding growth in 2016/17 was far higher than it will be over the next two years (under current pre-election spending plans).

It’s worth mentioning here that although the access standards were not achieved, more than 400 000 more patients received elective care within 18 weeks (from referral) and almost 6000 more patients received treatment for cancer within 62 days in 2016/17 compared to 2015/16. So the NHS is treating more patients than ever before, but not enough to maintain the level of activity needed to meet national standards.

To address this, the government and NHS England have decided to focus on attaining the A&E access standard in 2017/18; performance against this standard dipped to 89.1% in 2016/17. The NHS will need to improve aggregate performance to 90% by September 2017 and the majority of hospitals should be meeting the 95% standard by March 2018. The national bodies are adopting a three pronged approach to achieve this.

Firstly, prioritisation. The NHS mandate for 2017/18 and the Next Steps on the NHS Five Year Forward View make it clear that the A&E—and 62 day cancer—standards must be met in 2017/18, while the 18 week elective treatment target is only mentioned in reference to targets being met “by 2020″—effectively downgrading it for now.

Secondly, incentives. NHS hospitals will again, in 2017/18, have financial and performance targets to meet to qualify for their share of the £1.8 billion available from the sustainability and transformation fund. However, in 2017/18 their performance will only be judged on whether they meet their A&E target, unlike in 2016/17 when they had to meet cancer targets and elective treatment targets as well.

Thirdly, funding. The spring budget announced £100 million in capital funding for new triage models in A&E. The additional £2 billion announced in the budget for social care is also supposed to free up hospital beds and, in turn, speed up the transfer of patients who require admission from A&E.

Will this be enough to get back on track? Although performance against the A&E standard improved to 90% in March 2017, fewer than one in 10 of the NHS finance directors in our QMR survey were confident that the NHS will be able to maintain this performance and hit the interim target. Fewer than one in five finance leads in clinical commissioning groups (CCGs) were confident.

Whether the prioritisation of A&E standards in 2017/18 will work or not, it will have a knock-on effect on elective services. Half of the CCGs responding to our QMR survey said that their financial forecast will depend on delaying or cancelling spending this year, while 40% of CCG finance leads are reviewing or reducing planned elective activity in 2017/18. However, the remainder are not, illustrating that reprioritisation is very difficult once contracts with providers have been signed.

The consequences of the focus on the A&E standard—longer waiting times and waiting lists for elective care—are acknowledged, but the scale of the potential impact is unknown. The Next Steps document predicts that the median wait for elective care “may move marginally,” but doesn’t go as far as defining what the forecast is, let alone what NHS England would deem acceptable.

But waiting lists don’t shrink on their own accord: every patient on a waiting list will need to be treated at some point. Most patients will continue to wait for treatment to begin, but some may find themselves accessing NHS services through other routes if their symptoms worsen while they wait. For example, patients requiring restorative surgery might make additional visits to their GP to review their pain and have additional prescriptions for pain relief to manage this.

And if the A&E standard is met again by March 2018, what then? How will trusts maintain access to A&E services within standards when there is a large backlog of elective work? Does elective activity then become the priority over A&E? Do they compete? And where does this leave the NHS Constitution, which gives patients a legal right to access elective services within 18 weeks but gives only pledges (not legal requirements) to meet the A&E target?

With NHS leaders effectively acknowledging that the service cannot continue to achieve the current set of finance and performance targets, the questions now are: what level of access is acceptable across the full range of NHS services, when can this be achieved, and how much will it cost?

James Thompson, senior research analyst, policy, the King’s Fund. 

Competing interests: None declared.

This article first appeared on the King’s Fund website here.