NHS gooroo blog

Archive for April, 2011

The headline 18 week target was narrowly breached in February, and in this post we’ll dive into the England-wide figures in more detail. (The King’s Fund also has analysis here. If you want local figures, you can find a map of the 18 week pressures here.)

First, the trend over time. The next chart shows how long the longest-waiting 10 per cent of patients waited in February. We have chosen 10 per cent because it is directly comparable with the headline target (that 90 per cent of patients should have waited less than 18 weeks when they are admitted).

In the following chart there are two lines: one for the headline target (those patients who were admitted, solid line, adjusted basis), and one for the underlying pressures (those patients still waiting, dotted line).

The headline target was breached because the solid line edged up above the 18-week mark. Can’t see it? Alright, here’s a blow-up of the same chart:

Personally I would say it’s a little early to declare a trend. But the solid line has certainly been rising hesitantly for a few months, and it did breach the target for the first time in over a year.

More significantly, the dotted line (which shows the underlying waiting time pressures) has remained above 18 weeks since late last year, and has clearly been rising since last spring. Now that does look more like a trend. If hospitals respond by trying to admit their long-waiters then we would expect their efforts to hold the solid line above 18 weeks too. The trouble is that not all Trusts do this and so the solid and dotted lines are not as strongly bound to each other as they should be; Trusts can simply ignore their long-waiters, and achieve the headline target by admitting only short-waiters.

So to get a fuller picture of what is happening, we need to look at each Trust to see how they are responding to the underlying pressures. The following video (introduced here) shows the position at each Trust over time. As in the charts above, these charts show the time beyond which 10 per cent of patients waited: red blobs for patients still waiting (the underlying pressures), and blue blobs for admitted (i.e. treated) patients (the headline target).

Looking at the video, things look much the same in February as in January. Here is the final slide, showing February.

The intriguing thing is that the blue blobs are starting to “boil up” again, which might indicate that Trusts are starting to relax their efforts to achieve the headline 18 week target. But it really is too early to tell.

The point where the red line crosses 18 weeks is almost the same as in January, as the following chart shows.

 

 

So 18 weeks remains under pressure. Will the headline target be breached again in March? It’s impossible to say, because the headline target is not closely linked to how long still-waiting patients are waiting. It is high time this peculiarity was removed, by amending the secondary legislation and standard NHS contract that encourage it, leaving Trusts free to do the sensible thing and tackle long-waits by treating long-waiters.

Doing surgery? Then you need anaesthetics on-site. Obstetrics? Then you need paediatrics.

Acute care is a tangled web of interdependent services, joined by so-called “clinical linkages”. Pull out something innocuous-looking, such as physiotherapy, and the whole thing collapses.

These clinical linkages were all mapped out in an earlier post, and Roy Lilley picked it up in his discussion about competition and regulation (as did Paul Leake). His argument was that competition in healthcare provision could lead to these clinical linkages being unpicked, with disastrous results; therefore any local service reconfigurations would need to be managed (and not left to the forces of competition) in order to preserve these clinical linkages.

So how real is this threat?

Let’s start by sketching out the scenario we are worried about. A healthcare provider (it doesn’t really matter if they are NHS or private) sets up a new elective facility, which attracts work away from the neighbouring NHS acute hospital. This destabilises the NHS hospital and triggers the closure of its acute services (including A&E), much unhappiness for local people, and a political row.

There are three possible ways in which the new provider could destabilise the old:

1. by financial cherry-picking: diverting away from the old provider a lot of highly-profitable elective work that had been subsidising the loss-making clinically-linked acute services;
2. by deskilling: diverting away a lot of elective activity, so that clinicians at the old provider are no longer seeing a big enough caseload and become deskilled, so that those clinicians can no longer provide a safe acute service on which other acute services depend;
3. by poaching: recruiting clinicians away from the old provider, causing the closure of a service on which other acute services depend.

In the Parliamentary committee debates on the Health and Social Care Bill, there was quite a lot of discussion of the problems that might be caused by “cherry-picking”. Monitor responded to these concerns in two ways: firstly to point out that if the problem is that elective procedures are more profitable than non-elective ones, then the solution is to change the tariff price and remove the distortion; and secondly that if economic destabilisation of acute services is the possible result, then Monitor can designate those services as essential and allow extra funding for them.

I would add a further point: it would be rash to assume that elective care is always profitable and acute care is always loss-making. So much in healthcare is characterised by gross and unexplained variations, and so there are likely to be many highly-profitable acute non-elective services, just as there will be many highly-loss-making elective services.

Deskilling is more pernicious, and would not be solved by flinging money at designated services. If surgeons are twiddling their thumbs all day because their elective workload has disappeared down the road, they are not going to be as practiced when surgical emergencies come in. Recruitment and retention would also go to pot. If you lose acute surgery, then acute medicine is at risk and so is A&E. What can be done?

Well, the first question to ask is: where is the new provider going to get its doctors from? In the middle of London, it is quite possible to run a hernia factory from 9-5, Monday to Friday, keep a whole team of surgeons busy, and still leave plenty of elective work around for the rest of London’s NHS doctors; deskilling would not happen in that scenario. But could you do the same in Northampton or Stoke? In practice, you’d probably be using the same NHS doctors who work at the local NHS hospitals, and so they wouldn’t be deskilled, just maintaining their skills on a different hospital site.

For the sake of argument, though, let’s say you did manage to set up an elective factory in the shires without using doctors from the local NHS. Perhaps your medical staff have been brought back from retirement, or want to work family-friendly hours. Would that not pose a threat to the local NHS hospital? Indeed it might. But how might the NHS hospital respond? They could do nothing, and let their surgeons twiddle their thumbs on full pay, but that would be perverse. A more sensible response would be to make their surgeons available to the new provider on attractive enough terms, which sidesteps the deskilling problem and replaces lost income. So it looks as if the old provider could respond to the deskilling threat, and head it off.

What about the third threat: poaching? Well the short answer is that nobody is irreplaceable. The old hospital can just recruit some new doctors. And if the service is so unattractive that it is impossible to recruit, then the old hospital’s problems run much deeper than the arrival of a new elective provider.

So we have seen how a degree of flexibility by the old provider can help sidestep the threat of destabilisation by the new. But we have tacitly assumed in this scenario that both the new and old providers are traditional monoliths who operate hospital buildings, and employ clinical staff, and contract with the NHS commissioners.

Now let’s imagine a world in which those three functions are unbundled. One possible way of doing this would be for the doctors in the old NHS hospital to establish themselves as Chambers and contract directly with commissioners; then the Chambers pays the hospital for the buildings, nurses, diagnostics and so on. Now we can see how much easier it would be to avoid the deskilling problem, which was the most serious challenge we faced above.

Because each Chambers could work across multiple hospital sites, it could respond much more flexibly than a traditional hospital service that was anchored to its buildings. If deskilling ever became an issue, the Chambers could redeploy clinicians across different hospital sites to head off the problem. It could, for instance, supply the clinicians needed by the new provider, including (where it made sense) retired or family-committed doctors.

So it is far from clear that clinical linkages are necessarily threatened by competition in healthcare provision. And even if they are, a flexible and competitive provider market could respond by unbundling provider functions in a way that unties people from buildings.

It’s official, the headline target that 90 per cent of patients should be admitted within 18 weeks has been breached.

The underlying pressures (based on those patients who are still waiting, as opposed to those lucky enough to be admitted) remain elevated. The picture varies enormously around the country, so here are some interactive maps showing how the pressures vary from place to place.

The following charts show, for patients still waiting, the time beyond which one in ten patients have already waited (since referral). If you click on a pin, some details will appear in a balloon, and then you can click on the Trust name in the balloon to get a comprehensive analysis.

 

All specialties first:

 

View All specialties in a full screen map

And now a breakdown by specialty:

Cardiothoracic Surgery

ENT

General Surgery

Gynaecology

Neurosurgery

Ophthalmology

Oral Surgery

Orthopaedics

Plastic Surgery

Urology

 

(Data from Department of Health; mapping by BatchGeo)

The “Liberative” Government’s health reforms started life with a light and permissive vision of GP commissioning. But now they are mired in confusion. What happened? In short, the new vision collided with the old. Last week the Health Select Committee sided firmly with the old vision, calling for Consortia to be renamed as Commissioning Authorities with formal governance structures and stakeholder representation.

New vision or old, everybody wants commissioning to be done well. But what does commissioning mean, and how should it change?

In the conventional vision, commissioning starts with the carefully-assessed healthcare needs of your local population. Then you compare this against the services actually provided. Inevitably, you find plenty of areas where needs are not being met at all, or where provision could be improved, or where there is over-provision and ineffectiveness. Starting with the biggest mismatches, you work with other stakeholders to design new and better pathways, and then you seek providers to deliver them (or work with existing providers to improve things).

Conventionally, you manage “your” providers through the annual contracting process. You estimate the amount of activity to be done, and then apply the tariff price (if there is one) or negotiate a price (if there isn’t). You manage quality using Key Performance Indicators (KPIs). If quality falls short or activity is at variance with the contract volumes, then you apply the remedies specified in the contract.

So far, so familiar. But this is all office-based activity. What are the chances of it making a real difference to patients?

You hope to reach a position where need and provision roughly match. But your experience shows that anything you measure in healthcare displays huge and unexplained variations; if you do find a match between need and provision, it is only by chance. And if you achieve a match today, then it probably won’t match tomorrow. So trying to match need with provision is going to be highly inexact at best.

0.5% of the population consumed over 20% of acute spend

Patients also show great variety even within a single pathway, and the sickest patients usually have multiple conditions. The harder you try to tailor a pathway to a particular condition, the more you find there are exceptions to the rule. Do these exceptions matter? Yes, because they are your most expensive patients. Data from one PCT shows that a mere 0.5 per cent of the catchment population (about 1,000 people) accounted for over 20 per cent of acute expenditure. So good judgement by GPs trumps good pathway specification when it comes to handling the sheer variety of patients presenting.

What about quality? You hope that quality and performance can be managed with KPIs and contractual sanctions. But “quality” is too rich a concept to be described in even the most comprehensive list of KPIs. The harder you try to specify everything, the more you lock yourself into the status quo. Moreover, anything that isn’t in the KPIs is simply driven out: the effort of monitoring everything else in the contract takes over. So quality needs to managed through dialogue, not specification, and the organised concerns of GPs are a better guide to quality than words in a contract.

Even activity – the crunchiest of numbers – is hard to control in the standard contract. You can try to limit elective activity if the waiting list isn’t rising. You can try to throttle cost by using activity caps and restrictions on “procedures of limited clinical effectiveness”. However, most contractual changes need to be implemented with the agreement of the provider (which may not be forthcoming), and in any case tactics such as banning procedures tend to be blunt and limited instruments that displace or defer the problem rather than solving it.

Finally, awarding contracts only to selected providers (especially if the contracts specify guaranteed volumes) involves saying “no” to other potential providers. The argument is that this helps to control expenditure, but again there is a lot of hoping going on: you hope that, by restricting the availability of providers, you will reduce demand. As Don Giovanni said in a different context:

Wer nur einer getreu ist,
Begeht ein Unrecht an den andern;

If I am faithful to one,
I am unfaithful to all the others;

Mozart

So the old vision of commissioning falls short on a number of counts. How could a new vision improve on it?

In commissioning, as with everything else in healthcare, real life happens in the consulting room not in the office. So better commissioning needs to happen in the consulting room too: if individual GPs manage their referrals and patient pathways well, then quality and budgets will follow. So the Consortium should focus its attention “downwards” to practices, rather than “upwards” to the Commissioning Board or “across” to providers.

That way, the life of a commissioner no longer revolves around the annual contracting round or the enforcement of KPIs. Instead, it revolves around helping GPs manage value, by:

• monitoring and escalating quality concerns raised by GPs;
• providing a “bank manager” function to GPs;
• peer-reviewing GP referral patterns and pooling risk;
• providing back-office, scheduling, and financial services to GPs;
• calling for new and better services, and helping prospective providers with their market research;
• ensuring that GPs are aware of the services and drugs available to them.

This moves decisively away from the adversarial contract-driven approach of the past. But one major step needs to be taken to make it work, a step that is not taken in the Health and Social Care Bill. Consortia need to be able to enforce budgetary limits at practice level, which is something that politicians (understandably) have tended to shy away from.

However, there is nothing to prevent GPs from opting to accept practice-level budgetary limits within their Consortium, or even formalising this rule in their Consortium’s constitution. After all, many GPs are pretty fed up with having their referrals interfered with, and their choice of providers restricted from on high, whenever PCTs are struggling to achieve their statutory duties because they cannot control demand.

So GPs and their Consortia are faced with a choice: genuine freedom to refer within a limited budget that they control; or a continuation of the imposed and inconsistent restrictions that face them now. What will they do? Perhaps the best outcome would be for different Consortia to make different choices. That would truly test the two visions of commissioning.