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Archive for June, 2011

Let’s take a closer look at the April waiting time stats just released by the Department of Health for England. (An overview, and interactive maps showing the pressures at all English Trusts, have already been published here.)

By specialty

All surgical specialties improved, England-wide, except for Cardiothoracic Surgery. Here are the time trends:

 

By Trust

The real variation appears when you drill down to Trust level. In the following time-series, each English Trust admitting over 50 patients in the month is represented by two points: a blue one showing how many weeks 90 per cent of patients were admitted within, and a red one showing how many weeks 90 per cent of patients still waiting had waited within. Each monthly chart is sorted, so that the red (still-waiting) points rise continuously.

http://www.youtube.com/watch?v=Wc6pg50mzCo

The final chart in the series is this one:

If you watch the blue dots in the video you will see that something interesting is happening. Towards the right of the chart, where Trusts have the greatest pressure from patients who are still waiting, the blue dots have gone up in the last few months. That means these Trusts are admitting more long-waiters, in an effort to tackle their waiting time backlogs (even though that looks bad on the admission-based targets). This is a very welcome development that will improve waiting times in the long run.

If we plot the red and blue dots against each other we can see how different Trusts approach the waiting times targets:

If a Trust is managing its waiting lists properly, you would expect to find it somewhere near the diagonal: the waiting times of patients being admitted should reflect the waiting times of those still waiting. Trusts who are above the diagonal are likely to be those tackling their backlogs; they admitted lots of long-waiters in April and waiting times for those remaining have come down.

However we can see that a number of Trusts are below the 18 week line (so they are meeting the headline admitted-patient target) despite having lots of long-waiters still on the list. The most extreme example, where 10 per cent of those still waiting are over 42.6 weeks is University College London Hospitals NHS Foundation Trust. Here is the detail, and it illustrates nicely how Trusts can achieve the headline target and have long waiting times. (You can get more reports like this for any Trust and surgical specialty here.)

The trend for the proportion of Trusts, where at least 90% of patients still waiting are below 18 weeks, is shown next. There was a slight deterioration in April, but nothing that looks like a trend for now.

Finally, let’s look at the Trusts with the biggest changes in their underlying waiting time pressures. The spectrum of change in the previous quarter looks like this:

Far more Trusts got better than worse, which is good news. The Trust with the biggest deterioration is Surrey and Sussex Healthcare NHS Trust, where 90th centile incomplete pathways waits have shot up since February. The Trust with the biggest improvement is South Warwickshire NHS Foundation Trust, which had longstanding waiting time pressure that has come down rapidly since December as commissioner restrictions started to bite. You can find the time trends for both Trusts here.

In April, as anticipated, referral-to-treatment waiting times came down in England:

• 90 per cent of patients still waiting were below 17.4 weeks (down from 18.5 weeks in March), so the underlying long-wait pressure was down.
• Only 9.5% of patients still waiting were over 18 weeks: the best since July 2010.
• 90 per cent of admitted patients had waited less than 17.9 weeks (down from 18.3 weeks in March): the first time the (not very helpful) headline 18-week target has been met since January 2011.
• The number of very-long waiters, still waiting after 52 weeks or more, was 13,435 (down from 14,355 in March).
• All surgical specialties held steady or improved, on both the still-waiting and admitted 90th centile waiting times, with the exception of Cardiothoracic Surgery which has been worsening since December 2010.

There was one piece of bad news, though. The total size of the waiting list rose to 2,474,210 – the highest since November 2010. Compared with March, the April list was nearly 20,000 bigger, and we don’t have to look very hard for an explanation because admissions were 75,000 lower, and non-admission treatments were 200,000 lower than in March.

Why the drop in treatments? This is a seasonal thing that has happened every year since 2007 (with the exception of 2008 when the 18 week target was being met). It is too early to say whether this has anything to do with the financial squeeze.

In the following chart, both lines show 90th centile referral-to-treatment (RTT) waiting times (i.e. 10 per cent of patients waited longer than the time shown by the line). The solid line shows how long admitted patients waited (this is now back below 18 weeks), and the dotted line shows waiting times for those patients who are still waiting (this peaked during the winter and is now coming down).

For the full details, our waiting time fact-checker is here:

RTT waiting times fact checker – April 2011

Maps of waiting time pressures

Here is a collection of interactive maps, one for each main specialty, showing the underlying waiting time pressures around England. You can click any Trust’s pin to get more detail in a balloon. You can also click the Trust’s name in the balloon for a more comprehensive analysis with benchmarking and time trends.

General Surgery
Urology
Orthopaedics
ENT
Ophthalmology
Oral Surgery
Neurosurgery
Plastic Surgery
Cardiothoracic Surgery
Gynaecology
Total of all specialties

 

This post first appeared in HSJ blogs

There are currently eight measures of waiting times in common use at English acute Trusts.* Bizarrely, a Trust can meet six (and in the short term seven) of these measures, cost-free, by refusing to treat any patient who was referred more than 18 weeks ago.

The odd one out is the most important measure of all: the 95th centile waiting time for incomplete pathways. Of the eight, this is the only measure that looks at long-waiters who are still waiting. But with all those other measures floating around, how easy is it for Trust Boards to home in on the one that really matters?

After reviewing the published Board papers on 165 Trust websites, here is an answer to that question. It looks as if many Trust Boards are pretty much in the dark. Here’s the data:

I managed to find referral-to-treatment (RTT) monitoring data on 91% of non-FT websites and 49% of FT websites. Probably the others examine the data in private session. So the following stats are based on the 111 Trusts’ performance reports that were published, all of them covering data periods in late 2010-11.

The most popular measure monitored was the longest-standing one: the admitted and non-admitted RTT percentage within 18 weeks: 82 per cent of Trusts monitored this.

Next most popular was the admitted and non-admitted median RTT wait: 39 per cent of Trusts.

Then admitted and non-admitted 95th centile RTT wait: 35 per cent of Trusts.

Bottom of the list was the most important measure of all: the incomplete pathway 95th centile RTT wait (invariably accompanied by the incomplete pathway median): monitored by only 25 per cent of Trusts.

Happily, many Trusts also presented data that is not nationally specified, to help their Boards understand their backlog pressures. So if you count up all the Trusts that present data on either the number of patients waiting, or the longwaits, or the over-18 week backlog, or any combination of the three, then that covers 58 per cent of them.

Which means that nearly half of Trusts gave their Boards no information about those patients who were still waiting.

nearly half of Trusts gave their Boards no information about those patients who were still waiting

Does this matter?

It is entirely possible that Trusts were giving their Boards all the information they needed in private session. We have no way of knowing, although most Trusts provide such voluminous performance reports in public that it would perhaps be surprising if even-bigger reports were handed out in private.

What we can rule out is the possibility that, if a Trust doesn’t mention long-waiters who are still waiting, that is because there isn’t a problem. To take a real-life example, here are all the published 18-week performance measures for a Trust with a significant and growing long-wait problem:

The covering paper for this Trust’s performance report contains no commentary on 18 weeks. So if you were, say, the local MP, or even a non-executive director at this Trust, you might assume from this data that everything is alright on 18 weeks.

And yet the underlying picture shows that everything is not alright. The analyses that follow were prepared by us from Department of Health data, and not included in the papers given to the Trust Board. The next chart shows that lots of patients are already waiting more than 18 weeks after referral (look at the dotted red line):

The time trend shows that things have been deteriorating rapidly since last summer (look at the dotted red line again):

I understand that Trusts are in a difficult position, when the “system” is monitoring so many waiting times measures, and when so few of them are particularly useful. On the other hand it is surely worth remembering that, if the waiting list is kept under control, then all the other measures will follow.

So would it not be better for Trusts to focus attention on the measures that really matter, and relegate the other parts of the scorecard to an appendix?

Or, put another way, if the waiting list is blowing out then why not say so?

 

* The median and 95th centile waiting times for admitted, non-admitted and incomplete pathways, plus the percentage admitted and non-admitted within 18 weeks.

(This post first appeared in HSJ blogs)

Over the weekend, a local paper in North Wales reported:

Shock rise in North Wales hip and knee surgery waiting times

THE number of patients waiting more than nine months for hip and knee replacements has rocketed by 11,700%.

In March last year just 16 people in North Wales had to wait more than 36 weeks for orthopaedic treatment such as joint replacement surgery. But that number saw an astonishing jump to 991 as of March this year. There has been a similar surge nationwide over the same period, from 38 to 4,466.

The shadow health minister, Clwyd West Tory AM Darren Millar, says the increase is “shocking” and “beggars belief”.

It’s a good thing they didn’t go back another couple of months for their percentages, or it would have been “over 40,000%” and Darren Millar might have stopped breathing altogether.

Digging beneath the figures at StatsWales confirms the story, and shows that The Daily Post picked out the right specialty from all the data: nearly all of Wales’s very-long-waiting patients are in Orthopaedics.

What is happening? Is the whole waiting list going up, or are the figures being skewed by local pressures in a few places? Bad news: this is happening right across Wales, with large increases in every Local Health Board.

The Welsh waiting list has grown by nearly 50 per cent in just 14 months, both for Orthopaedics (from 41,876 to 61,986) and for all specialties combined (from 231,947 to 345,554). So although Orthopaedics is worst for long-waiters, other specialties are heading for trouble too.

How do we explain this? In the news article, the Welsh Government pointed to increasing demand for orthopaedics. So perhaps GP referrals have been soaring? (If you’re digging up the figures yourself, unfortunately there seems to be a gremlin in the StatsWales database for GP outpatient referrals, but the obviously-wrong figures can be filled in from the statistics releases for the all-specialties figures.)

The upward trend across all specialties is 1,730 extra referrals a year, which doesn’t explain a waiting list that is shooting up at nearly 100,000 a year. Nor does the upward trend for orthopaedics, at 177 a year, explain the 17,000 a year rise in the waiting list. According to the referrals figures, demand doesn’t seem to explain the rise.

Have the hospitals slammed the brakes on treating patients then?

 

 

No sign of any dramatic slowdowns. In fact, the trend is slightly up.

So how can we explain the dramatic and continuing increase in Welsh waiting times? On the strength of these figures, sadly, we can’t. We need to dig even deeper.

But something needs to be done in Wales, and quickly, to turn this around. On the current spending plans, that “something” will need to be more imaginative than buying more activity. If anyone in Wales knows how to explain the increase, or better still how to reverse it, then comments are welcomed below.

 

(This post first appeared at HSJ blogs)