NHS gooroo blog

Archive for December, 2010

The Operating Framework was published on Wednesday, and lays out the planning headlines for the NHS next year. There is plenty of commentary on the financial settlement elsewhere, which I won’t repeat: see for instance the Nuffield Trust and the HSJ.

So in this post I’m going to focus on the 18-week waiting time target, which journalists everywhere still seem to believe has been abolished. It hasn’t. This is what the relevant paragraph of the Operating Framework says:

Referral to treatment times

4.24 Patients’ rights to access services within maximum waiting times under the NHS Constitution will continue and commissioners should ensure that performance does not deteriorate and where possible improves during 2011/12. With that in mind, providers should be expected to offer maximum waiting times to patients and there will be monitoring of compliance with this and the 95th percentile of waiting time. The median wait will also continue to be monitored with a view to improvement. The existing cancer waiting times standards support better clinical outcomes and will continue to apply.

So why do so many journalists think the 18-week target has been abolished? Because the Revision to the Operating Framework for the NHS in England 2010/11 said:

7. … Performance management of the 18 weeks waiting times target by the Department of Health will cease with immediate effect.

even though it went on to say

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.

So if national enforcement of 18 weeks has ended, what levers are left for DH to pull? The new Operating Framework says:

6.3 The priorities set out in this NHS Operating Framework need to be planned for in the context of the system levers:

• the NHS Constitution, which secures patient and staff rights;
• the contract, which needs to be the pre-eminent means of doing business between commissioners and providers;
• the Care Quality Commission, who provide regulatory assurance that essential levels of safety and quality are being met; and
• Monitor’s Compliance Framework, which ensures that NHS FTs are meeting their terms of authorisation, including delivery against the national priorities set out in this NHS Operating Framework.

So the Constitution sets the standard and, if the other three levers continue as they are, then the contract will specify the penalty regime for failure, the CQC may or may not look at waiting times under periodic review, and Monitor won’t monitor.

So to find out what the 18 week target actually is, we need to look at the NHS Constitution. Or rather, the Handbook to the NHS Constitution, because the Constitution itself isn’t specific about waiting times. The Handbook says, on waiting times:

This is a new right and there is new legislation to support it. From 1 April 2010, you will have the right to:

• start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions; and
• be seen by a cancer specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected.

If this is not possible, the PCT or SHA which commissions your treatment must investigate offering you a range of suitable alternative providers that would be able to see or treat you more quickly than the original provider. You will need to contact the provider you have been referred to or your local PCT before alternatives can be investigated for you. Your PCT or SHA must take all reasonable steps to meet your request.

So how firm is this requirement that commissioners must take “all reasonable steps” to “investigate offering you” these “suitable alternatives”? For the answer we have to go to the legislation, which in this case is The Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010:

Duty to make arrangements to meet 18 week operational standards

2. Each Primary Care Trust and Strategic Health Authority must make arrangements to ensure that any provider providing services to persons for whom that Trust or Authority is responsible complies with the operational standards relating to patients on an 18 week referral to treatment pathway as set out in Annex 1 of the NHS Performance Framework: Implementation guidance published on 24th April 2009.

Duty to have regard to the guidance

6. In carrying out its duties under directions 2 and 4 each Primary Care Trust and Strategic Health Authority must have regard to—

(a) the documents entitled “The 18-Week Rules Suite” published on 5th March 2010; and

(b) the guidance document entitled “Implementation of the right to access services within maximum waiting times” published on 8th March 2010.

This is turning into a real paper-chase. How many NHS managers have the time to track all this stuff down? Surely we must have reached the end of the trail now, and will actually find the 18 week standards?

Thankfully, we have. Annex 1 specifies the well-known 18 week targets:

Performance Indicator	Achieve	Fail
18 weeks RTT – admitted	90%	85%
18 weeks RTT – non-admitted	95%	90%

…and this table is confirmed in the guidance document:

The operational standards of delivery for the NHS are:

• 90 per cent of pathways where patients are admitted for hospital treatment should be completed within 18 weeks; and
• 95 per cent of pathways that do not end in an admission should be completed within 18 weeks.

with enforcement referred back to the standard NHS contract between commissioners and providers:

2.47 The standard acute contract requires providers to comply with any obligations placed on PCTs relating to waiting times, including those under the Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010.

So there we have it. The target remains 90 per cent within 18 weeks RTT for admitted patients, enforced through the contract.

Or so it remains for the time being. A new contract will be issued soon, the NHS Constitution will be updated, and the previous Government’s Directions will no doubt be amended. When these changes are made, we can only hope that they will be spelt out clearly and simply for the NHS, instead of having to track through multiple documents in search of the standards.

Now, what can we do to persuade journalists that the 18 week target hasn’t been abolished?

A new video shows the power of better patient scheduling to reduce waiting times. It shows waits falling from 20 weeks to 14, just by managing bookings better.

What made the difference?

• the right number of slots was reserved for urgent patients
• urgent patients waited as long as was clinically safe for them
• only genuinely urgent patients were declared urgent

The video tells the story by itself. So let’s look instead at something the video doesn’t cover…

Follow-up outpatients

Imagine this: You are booking referrals into outpatient slots. Every routine patient gets the next available slot. You’re busy, and all slots are fully booked up for the next few weeks. Then an urgent referral arrives, and the patient needs to be seen quickly. But all the early slots are full. The only way to squeeze them in is to cancel someone else. But who?

In the video we assumed that a routine first appointment would be cancelled – whoever is least inconvenienced by the delay. But many hospitals prefer to cancel follow-up patients instead (usually two or three, in fact, because follow-up appointments tend to be shorter than new appointments). This lets them make space for the urgent patient, without putting extra pressure on their 18-week waiting time target by delaying a first appointment.

So which is better? If you have to cancel patients, should you cancel one routine first appointment, or two (or three) follow-ups?

To answer this, we need to look at follow-ups more closely. A follow-up patient should (if referred appropriately) be someone who needs to be seen during a specified window of time: for instance 2-4 weeks, or 5-8 months, after their previous appointment.

The first thing to point out is that some patients are followed-up unnecessarily, so the first priority should be to ensure that patients are only followed-up for the right reasons. Clogging up the clinic with unnecessary follow-ups is a waste of clinicians’ time, and the patients’.

Now let’s look at this time window. If the patient could just as well be followed-up after 8 months as 5, then it makes sense to go for 8 months. Why? Because it reduces the number of follow-up appointments in any given year, releasing capacity for other work. Otherwise you end up seeing patients more often than necessary, which again wastes everybody’s time.

But there is a consequence. Once the patient reaches the 8 month mark, they really do need to be followed-up now. In effect, they are clinically urgent. So we can’t cancel them. We should cancel a routine first appointment instead, if we have to.

So the story told by the simulation video is the right one. We should cancel routine first appointments, not follow-ups, if we need to make space for urgent referrals. As the simulation shows, it is possible to do this and keep waiting times to a minimum.

We talk about the demand for healthcare all the time, but sometimes the talk is loose. If you hang around NHS offices for long enough you might hear statements like:

• Demand can’t be that high – the contract doesn’t provide that much.
• Last year we did 1,000, add 3% growth in demand, so that makes 1,030 next year.
• I’ve got hips coming out of my ears.

…and so on.

This kind of talk confuses demand and activity. More accurately, we might say things like this:

• Demand is likely to grow, but we don’t know exactly why or by how much.
• The waiting list is the accumulated mismatch between demand and activity.
• If we want to control waiting lists, we have to at least keep up with demand.
• Historic demand is activity plus the growth in the waiting list (adjusted for removals).

This is the sort of thing that is built into good planning models, and it allows us to make other useful distinctions, like:

• recurring activity is the activity required to keep up with demand; and
• non-recurring activity is everything else, and it brings down the waiting list.

So far so good. But behind all this, we are making a big assumption that won’t spring out of a planning model: that all our “demand” represents real work that we need to do. For instance:

• a patient is seen in outpatients by the wrong consultant and has to be rebooked with the right one; is the first appointment “demand”?
• a patient is referred for unnecessary follow-up by a junior who is not confident enough to discharge; is this follow-up “demand”?
• a patient is seen in outpatients, but the necessary test results aren’t ready so they have to be rebooked; is this “demand”?
• a one-stop clinic replaces an outpatient-diagnostic-outpatient sequence; does demand fall by two-thirds?

And on the inpatient side, are any of the following “demand”?

• a patient remains in an acute bed for a couple of days longer than necessary, waiting for a ward round and then drugs;
• a patient arrives for surgery, but is sent home and rebooked because they had toast for breakfast;
• a patient is admitted to avoid breaching the 4 hour A&E target, even though they don’t meet any AEP criteria.

These examples of “demand” are not caused by unmet healthcare needs in the population. Rather, they are artefacts of the system. How much of our total demand is created like this? 3 per cent? 10 per cent? 30 per cent? Do we have the faintest idea?

If it’s a sizeable proportion, and I suspect it probably is, then reducing it could substantially offset the (apparently) growing genuine demand for healthcare. Which would be handy at a time of near-frozen real-terms funding.