NHS gooroo blog

Archive for July, 2010

The White Paper was like diving into a British lake: a cold shock, a rush of blood, a feeling of disorientation, and yet all somehow very invigorating and healthy.

The SHAs are being abolished, and they will not be missed. I hope that now all the stories of bullying, extra-legal activity, and jobs for the boys will come out. The SHAs filled a gap in the organisational chart of top-down control, but in practice they neither insulated Ministers enough for Ministerial comfort, nor showed enough willingness to place Government policy above local issues to be genuinely useful to them. Soon they’ll be gone.

The abolition of PCTs has been deftly done. Now that so many PCTs are coterminous with local authorities, many people expected functions to transfer over. Health improvement is a natural transfer. So is the join with social care. Handing commissioning to GPs is also natural; in fact GPs have always done the commissioning because they refer the patients. What’s left? An untidy bag of statutory duties will need sorting out, but they are not enough to justify the PCTs’ existence. So off they go.

What emerges at local level is very different from the longstanding model of monopoly hospital toughing it out with monopsony commissioner. In its place we will have something more like a normal market, with many independent commissioners (the GP consortia) buying care from a much smaller number of hospitals. This is very much to be welcomed.

So what could go wrong? Plenty of course, and it will.

Quality will inevitably become much more variable around the country. So expect a lot of complaints about health inequalities and postcode lotteries, even as overall quality improves.

There also will be complaints about the funding formula, because as it is applied more locally, funding will become more variable. The strength of the assumptions being fed into the formula will start to look shakier on close local scrutiny, and the most likely result will be a simplification of the formula and a reduction in funding variation, amid loud complaints from the biggest losers.

Some hospitals will struggle to achieve Foundation status, and some Foundation trusts will flounder (as is happening already). As noted in an earlier post, many hospitals would work better if their monolithic structures were broken up, to separate the different clinical, operating and property functions within them. As with GP commissioning, this would be no more than a reflection of reality: consultants have always been clinically autonomous, and so it would make sense to rediscover their heritage and become organisationally and economically autonomous again too.

Some GPs will struggle with commissioning, especially in the early stages. But a penumbra of independent-sector services will emerge to provide the specialised services they need. This penumbra will not necessarily be big companies from overseas; their chances were better when they had big government to talk to. No, the GP consortia will be much smaller outfits, and will deal easily with boutique companies (like gooroo) providing very well-targeted expertise for the local situation, with each GP consortium remaining in control as customer.

The separation of GPs’ personal fortunes and their commissioning budgets will be crucial, and difficult. GPs will be establishing out-of-hospital services for conditions like diabetes, COPD, and cardiology, referring patients to those services, and profiting from providing them. It will appear that they are pocketing their commissioning budgets in the process, and there will be sufficient wriggle room in the application of the tariff to blunt protestations that they are simply competing on a level playing field. Handling this blurring of boundaries between commissioning and providing will probably be the commissioning regulator’s biggest challenge.

The regulators will face constant temptation to extend their powers and intervene more. Every scandal and every failure will bring calls for Ministers and the regulators to “do something”. These temptations to recreate SHA-style powers through the regulators will need to be firmly resisted if GP Commissioning is to flourish and providers are to become more responsive. The heavier the hand of regulation, the more everyone will look to the regulator instead of to the patient.

As the feelings of disorientation wear off, and as the detail of these changes becomes clearer, it will start to feel as if there are more problems than solutions in these changes. However, a decade from now, I think we will all look back and wonder how we ever tried to run the NHS as a management hierarchy, defying the reality that doctors were autonomous all the time.

How can you cut waiting times? The conventional wisdom is:

• keep the number of patients waiting to a minimum, and
• schedule patients of equal clinical priority in turn.

And the conventional wisdom is correct. But the problem is that the conventional wisdom is also difficult to implement.

Which of your patients have absolutely equal clinical priority? What about all the cancellations and removals that mess up your scheduling? Scheduling is complicated, so unsurprisingly it has been rather neglected over the years. Instead, the focus has been on the number waiting: laying on waiting list initiatives to clear the longest-waiting patients from the list (and then watching in dismay as the long-waits reappear later on).

Yet better scheduling makes a huge difference, and the only cost is managing it. You can see the difference for yourself. Here are some patients who are, shall we say, not being managed terribly well (even though routine patients are mostly being managed with great discipline, and not a minute of capacity is being wasted). The maximum waiting time in this example is 16-18 weeks.

And here are the same patients being managed much better. The maximum waiting time is 11-12 weeks.

If you took the poor example, and just did a waiting list initiative, you would need to reduce the list size by about 25% to get down to 11-12 weeks. That’s only a 20-patient reduction in this case, but then this is only one consultant’s outpatients. Try cutting 25% off the list for all consultants with waiting time pressures, including their inpatients and daycases, and the cost… well, you can estimate it yourself, but it’s going to get rather expensive. Much better to get the scheduling right first.

You can learn how to schedule better using SimTrainer, get operational assistance with scheduling using SimActive, and run your own booking simulations with SimView; click here.

Some years ago, when Gordon Brown was Chancellor, I met his right-hand man Ed Balls at the Treasury to talk about waiting times. It is difficult to imagine now but, back then, inpatients waited up to a year for their operations. Ambitious Ministers wanted to cut this radically.

I advised that a 9 month target would be easy to achieve at minimal cost, but a 6 month target would require substantial extra resources to cut the size of the waiting list. When I stressed the costs involved, I was surprised to find that Mr Balls was unruffled. But of course, back then, I had no idea just how much extra resource they were willing to commit.

Soon after our meeting, the Labour Government opened the spending floodgates and poured money into the NHS, announcing that they effectively wanted to abolish waiting lists. A brutal performance management regime was created with monitoring, threats, naming and shaming. As NHS expenditure trebled from its 1997 level, capacity expanded, waiting lists came down, and the 18-week referral-to-treatment waiting time was (with only a few exceptions) achieved across England.

A report by the Nuffield Trust shows that both money and pressure were necessary in achieving 18 weeks. England achieved short waits, but Scotland, Wales and Northern Ireland did not (despite spending more money and having more staff). In short, both blood and treasure were spent; lots of it. The 18-week target was hard-won.

Times have changed. The money has run out, and a new Government has been elected to clean up the mess. At the Department of Health, the new Secretary of State has wasted no time in shaking things up with a new Operating Framework for the NHS.

The changes to the 18-week target caught the headlines. They are “a very risky message that waiting no longer matters”, said Lord Crisp, a former NHS Chief Executive. “There is now a real risk that there will be a slipping back on the big improvements in waiting times of the last 10 years”, said Chris Ham, the King’s Fund Chief Executive.

So what does the new Operating Framework actually say? The key passage is:

18-weeks waiting times

7. NHS organisations have made significant improvements in access to elective care. Average waiting times now need to be reduced, in line with international experience. Accountability to patients and greater information transparency, through patient choice and the move towards GP-led commissioning, should now make long waits unacceptable. Performance management of the 18 weeks waiting times target by the Department of Health will cease with immediate effect.

8. To maintain progress during 2010/11:

• commissioners should maintain the contractual position and GPs and commissioners will want to ensure that any flexibility to improve access reflects local clinical priorities; and
• referral to treatment data will continue to be published and monitored. Commissioners will want to use the median wait as an additional measure for performance managing providers.

9. Patients’ rights under the NHS Constitution will continue, as will the accompanying legal requirements to ensure that providers are achieving the waiting time rights. We are considering to what extent amendments are required, and if so, we shall carry out a full consultation in due course.

So the brutal performance management regime has come to an end, to the relief of Chief Executives who feared the phone call if the target was breached on their watch. In its place are the NHS standard acute contract (with financial penalties of up to 5% of total elective income for breaching 18 weeks) and the NHS Constitution pledge, backed up by the Waiting Time Directions 2010 (which require PCTs to “take all reasonable steps” to arrange an earlier appointment if a patient complains she is waiting too long).

These measures have the potential to be firm, if they are actually implemented locally. However the experience of the past suggests that, when the going gets tough, too often the easiest option for both commissioners and providers is to let the patients wait. We shall have to wait and see how well this hands-off approach works.

What are we to make of the waiting time statistics mentioned in the revised Operating Framework? First it talks of the need to reduce average waiting times. Average waiting times are directly proportional to the size of the waiting list divided by the rate that patients are added to it (assuming casemix remains constant). So in practical terms that means that waiting lists must rise no faster than referrals. A sensible measure.

But then it asks commissioners to monitor median waiting times. This means that if you take all your patients, and sort them in order of their experienced waiting times, then the middle one (50% of the way down the list) has the median wait. Is this a sensible measure? Consider this: if 20% of the patients are urgent, and the rest are broadly seen in turn, then the median wait (the 50% wait) will be close to the maximum wait. But: if 70% of the patients are urgent, then the median wait will be very short because it is experienced by an urgent patient. So monitoring median waiting times makes little sense at first sight.

It gets worse. Let’s say 55% of patients in, say, plastic surgery are being admitted as urgent patients, so your median wait is in the urgent zone and very short. But you examine the casemix carefully and find that some routine patients are being misclassified as urgents, which is clinically unjustified and causes other routines to wait longer. So you put this right, obeying the contractual guidance that:

9.3 Providers are expected to follow recognised waiting list management practice such as taking patients of equal clinical urgency in turn.

So now only 45% of these patients are being admitted as urgents, which is a more accurate reflection of the casemix. But your median waiting time has increased dramatically, because now it reflects typical routine waiting times instead of urgent waiting times. Improving your scheduling has sent median waits in the “wrong” direction.

So on 18-weeks, the new Operating Framework can be criticised on two grounds. Firstly the lifting of central performance management is likely to cause the target to slip once the financial squeeze takes effect; at worst, maximum waits could rise by one week every week. Secondly, the suggestion that commissioners should monitor median waiting times reflects ignorance of scheduling dynamics; I would suggest that if a centile is to be monitored then it should not be the 50th, but a high one such as the 90th centile. That would reflect more accurately the provider’s success at managing scheduling.