NHS gooroo blog

Archive for July, 2011

Yesterday I blogged about the England-wide picture waiting times. Today we’ll dive into the detail, and look at the variation between Trusts.

The all-specialties position

First, let’s look at the variation in waiting time pressures around the country, for all specialties added together. In the chart below, each Trust is represented by two dots: a red dot showing how long the top 10 per cent of the waiting list is waiting (i.e. 90th centile RTT waiting time for incomplete pathways), and a blue dot showing how long the top 10 per cent of admitted patients had waited (i.e. 90th centile RTT waiting time for adjusted admitted pathways).

Trust waiting time pressures May 2011

So the red dots show, roughly speaking, how big the long-wait problem is at each Trust, and the blue dots show what they are doing about it.

Over to the right, where we find Trusts with the largest pressures on their waiting lists (the red dot is high), we can see that many are admitting lots of long-waiters in an effort to solve the problem (the blue dot is also high). Unfortunately if the blue dot is above the 18-week line it also means they are failing against the government’s main RTT waiting time target (which, as I am still not tired of pointing out, penalises Trusts that do the right thing and treat their long-waiters).

But we can also see that many Trusts with large long-wait pressures on their waiting lists are not tackling their long-wait problems, and are instead choosing to achieve the government’s main target. I don’t blame them for doing this; the penalties can be severe. The problem is the target, not the Trusts who choose to achieve it. Until the government changes the target so that it focuses on patients who are still waiting, not those treated, the extreme long-waits we are now seeing will continue to worsen.

Which Trusts have the biggest waiting time pressures? Here’s the top twenty (which may or may not be missing Kingston and St George’s, neither of whom submitted data for May):

We can also see in the above chart that 68 per cent of Trusts have red dots below the 18 week line, which continues the improvement seen since the winter as the following chart shows:

Where the red line crosses 18 weeks

Specialty by specialty

Drilling down to the individual specialties, we find even more variation. Here are the England-wide pressures on the waiting list, by specialty over time:

Time trend by specialty

With the exception of small upticks in ENT, Oral Surgery and Gynaecology, all surgical specialties improved in May. Of the big surgical specialties the greatest pressures are, as usual, in Orthopaedics (90 per cent of the waiting list over 19.6 weeks) although the gap is narrowing with Urology (19.3 weeks) and General Surgery (18.8 weeks).

Around the country there is, as for the all-specialties picture, enormous variation from Trust to Trust. So here are some interactive maps of the pressures around the country, specialty by specialty. You can click on any pin to get a balloon with details of that Trust, and then click the Trust name in the balloon to get a fuller analysis:

General Surgery | Urology | Orthopaedics | ENT | Ophthalmology | Oral Surgery | Neurosurgery | Plastic Surgery | Cardiothoracic Surgery | Gynaecology | All specialties

Finally, to illustrate, here is the Orthopaedics map. Go ahead and click it!

Orthopaedics map

 This post first appeared at HSJ blogs

What happened to waiting times in May? Reporting on the newly-released referral-to-treatment (RTT) waiting times for England, The Guardian said:

Number of cases missing waiting time target of 18 weeks since GP referral soars by a third

The BBC said:

Waits rise ‘leaves NHS struggling to cope’

The Independent said:

More patients waiting longer

The Labour Party said:

Rise in long waits for treatment shows you can’t trust Cameron to keep NHS promises

Even the Department of Health said, rather defensively:

We are committed to keeping waiting times low. There are more people than ever before in the healthcare system.

Crikey. It sounds like a real bloodbath. So what actually happened?

If you want to look at the detail, you can download all the data in our waiting times fact checker here:

RTT_waiting_time_fact_checker-May_2011.xls

First, here’s the trend for the total number of patients waiting, charted to bring out the seasonality:

Total list size (English incomplete RTT pathways)

The number waiting went up, but no more than it did last year. No evidence of big trouble there, then. How about the long-waiters?

England time trend for long-waiters

The dotted line shows how long the top 10 per cent are waiting, if you look at patients who are still on the waiting list. Things have continued to improve since the winter, and long-waits are at their best since June 2010. And the number of very-long-waiters, still languishing on the list a year after referral, is down to 12,530, which is 12,530 too many but still the best performance ever recorded (it was 18,458 at the time of the election). No evidence of trouble there either.

What about the solid line? That shows how fast the NHS is clearing the backlog of long-waiters, and therefore isn’t really a measure of waiting time pressures at all. Nevertheless the Government perversely intends that it should be below 18 weeks, which it is, so no problem on the official figures either.

Where, then did these dreadful headlines come from?

The Guardian article says:

A total of 27,834 patients in England who received inpatient treatment in May 2011 had waited more than 18 weeks for it since being referred by their GP, compared to 20,504 in May 2010 – a year-on-year rise of 33.5%.

The Guardian don’t have the numbers quite right, but they’re close enough for our purposes. They are referring to the number of patients admitted as inpatients or daycases, who had waited more than 18 weeks since referral (adjusted admitted pathways). And these are indeed up by over 33% on the previous year.

Does that mean that waiting times are up? Not at all. It means the NHS admitted more long-waiters, and cleared some backlog. If we rewrote that sentence, looking at patients who are actually still waiting instead (and being a little less selective about the data points), it would read:

A total of 224,870 patients in England who are still waiting at the end of May 2011 had waited more than 18 weeks since being referred by their GP, compared to 276,871 in February 2011 – a drop of 18.8%. However this is more than in May 2010 when only 209,411 were waiting more than 18 weeks – a year-on-year rise of 7.4%.

So how should we sum up the latest data? I’d say that things got steadily worse between the time of the election and the depths of winter, and have steadily improved since then. As the underlying pressures on the waiting list have eased, the Government’s preferred measures have followed a few months later.

There is an important caveat, though. Around the country, patients are being kept away from the waiting list with various rules about eligibility for treatment. We cannot know how many are affected. All we can say, is that the reported figures don’t tell the whole story.

In a post tomorrow, I’ll report on the detail at Trust level.

This post first appeared in HSJ blogs

Yesterday the Guardian Datablog (slogan: “Facts are sacred”) published a piece on NHS waiting times, which I am afraid I described on Twitter as being “truly awful”. @tobyhillman gently asked if I could “deconstruct in a blog, would be good to have comparison/ alternative presented alongside”. So that is what this post is all about.

The Guardian’s blog covered A&E, diagnostic and cancer waiting times too, but I’ll stick to my specialist subject of referral-to-treatment (RTT) waits. The Guardian’s piece promises:

New data journalism shows exactly how much worse NHS waiting times have got

But my main complaint about their piece is that it lacks any insight into the underlying dynamics of waiting times, and is therefore ill-equipped to deliver this promise. For instance:

For complex statistics, it’s often possible to extract the data in different ways to support different positions. With issues like NHS waiting times, the issues are rarely simple: as is happening at present, it is possible for the waiting time of a “typical” patient to fall, while thousands of extra patients face waiting times longer than those mandated in the NHS constitution.

This statement is true, but fails to expose the crucial point that reducing the waiting time of a “typical” patient can directly cause thousands of extra patients to wait longer, if lots of patients start jumping the queue without good clinical reason. Badly-set targets can cause this in real life: if you start forcing down the “typical” (i.e. median) waiting time with targets, as the NHS is now doing, then you are encouraging queue-jumping by routine patients and therefore putting upward pressure on long-waits.

The Guardian’s “Treatment within 18 weeks” panel is where they pull the numbers out:

Measure: Number of patient waiting over 18 weeks for hospital treatment
Change year-on-year: +11% (by patient numbers), or +24% (by percentage of patients affected) (April 2011 versus April 2010)
Patient numbers: 2,387 more people had waited more than 18 weeks for their treatment in April 2011 versus April 2010, despite the number of procedures carried out dropping by over 29,000
Description: The key waiting time measure introduced under New Labour, patients are guaranteed under the NHS constitution that they will receive their hospital treatment within 18 weeks of GP referral. The coalition government reaffirmed its commitment to this target as part of the NHS listening exercise, where it was one of David Cameron’s five pledges on the NHS.
Source: 18-week waits: “Referral to Treatment Waiting Times Statistics, Adjusted Admitted Pathways (Provider data)”, Department of Health

The first problem is that the NHS constitution guarantee does not cover the “Number of patient (sic) waiting over 18 weeks for hospital treatment”. It covers the waiting times of those patients lucky enough to be treated, not those patients still waiting. The Guardian’s instincts were right, though: the target should be based on those still waiting. But the Guardian has missed the big story again, which is that the Government is measuring the wrong thing: they are measuring the rate at which the backlog is being cleared, not the backlog itself. Even worse, they have set targets that limit how fast hospitals can clear the backlog. So the whole thing is upside down.

Secondly, the Guardian are being somewhat selective over their timeframes. April 2010 is close to the low point on several waiting time measures, so all those measures will look worse by comparison. The complete time trend tells a more interesting story of deterioration over the winter, followed by improvement.

England waiting time trends - all specialties

Finally, I don’t think they even have their numbers right. The increase in over-18-week adjusted admitted pathways over that timeframe is 2,353, not 2,387. It’s only a small difference, but a difference nonetheless. They quote the source as being provider data, which might explain the discrepancy; if you want to quote England-wide statistics you should use the commissioner data not the provider data.

The Deputy NHS Chief Executive of England, David Flory, has written a stern letter to all NHS Chief Executives:

The commitment to ensure patients receive treatment within 18 weeks of referral is embedded in the NHS Constitution and is a fundamental part of the NHS Contract. The Government has recently reinforced this commitment. I have personally stressed the need to maintain delivery of RTT through the meetings that were held with you to “sign off” plans for 2011/12. There can, be no doubt about the importance of delivering improved performance on waiting times, particularly for admitted patients.

Stirring stuff. But then he goes and spoils it:

Against this background, it is unacceptable for performance to fall below the expected standards as it did in February and March 2011.

But February and March were the months when the NHS sorted out its long-wait backlog. Here’s the chart:

England waiting time trends - all specialties

Watch the dotted line; it shows what’s happening to the waiting list backlog. Back in November, one in ten patients on the waiting list were waiting more than 18 weeks since referral. Then winter struck, the backlog grew, and at the end of January one in ten were over 19.4 weeks. Then in February and March the NHS sorted the problem out, admitting the longest-waiters and cutting the backlog down to pre-winter levels.

But the Department of Health weren’t watching the dotted line. They were watching the solid line instead. This shows the waiting times of the top 10 per cent of patients who were admitted. Clearing the long-wait backlog meant admitting lots of long-waiters, so in February and March the solid line went up, breaching the 18 week target level.

When, in all this, was the performance “unacceptable”? Surely not when the problem was being solved, in February and March? The worst performance was surely in December and January, when the backlog was allowed to grow? This letter is starting not to make sense.

And it goes on:

Recovery plans for the worst performing organisations were requested during the recent planning round. … I expect local support to be made available; contract levers to be applied in a robust way and for swift intervention where the necessary progress is not being made.

The “contract levers” he refers to are in the standard NHS contract. They include Schedule 3, Part 1, section 8, which provides for heavy financial penalties if Trusts admit too many long-waiters. So if a Trust has developed a long-wait problem, it isn’t allowed to tackle it by admitting lots of long-waiters. That’s like trying to solve over-indebtedness by limiting how fast people are allowed pay off their loans.

Surely the Deputy Chief Executive of the NHS in England cannot be encouraging Trusts to sweep their long-waiters under the carpet and ignore them? That would be truly astonishing, and yet… well, here is another shred of evidence.

On the very day he sent his letter, David Flory also published his report “The Quarter” which covers the same time period. On page 19 he lists the twenty-eight “Acute trusts with poorest performance on referral to treatment waits March 2011″.

There is a strange omission from this list of 28 recalcitrants. It is the Trust with the second-longest-waiting patients in England. At the end of March, 31 per cent of its waiting list patients were over 18 weeks, and 5 per cent were over a year. So how on earth did it escape the list? The answer is, this Trust wasn’t tackling its backlog. In March, only 5 per cent of its admissions were over-18-week waiters. That meant it achieved the headline target, and escaped the list of sinners.

Which Trust is it? It’s University College London Hospitals NHS Foundation Trust: the hospital where David Cameron promised not to lose control of NHS waiting times, just a few short weeks ago.  If the Department of Health wants to encourage Trusts to neglect their longest-waiting patients, it is going the right way about it.

The Scots usually take a pragmatic attitude to English policy initiatives: wait and see if it works, and if it does then copy it. So I have to admit that I groaned when I saw Scotland’s new waiting time targets. Failing to learn from English mistakes is perhaps excusable, but why make them even worse?

What has Scotland done? They introduced a referral-to-treatment (RTT) target that 90 per cent of patients will wait no longer than 18 weeks from GP referral to treatment, to be achieved by December. So far, so familiar. The problem? They are monitoring their progress by watching only the waiting times of those patients lucky enough to be admitted. Unlike England, they are not also monitoring the RTT waiting times of patients who are still waiting.

In England, we know from experience that hospitals can meet this target simply by ensuring that, of every ten patients treated, only one is a long-waiter. That is how some English Trusts manage to “achieve” the headline 18-week target, even if they have massive waiting lists with patients waiting over a year.

At least in England those patients who are still waiting (the “incomplete pathways”) are still monitored, so that this kind of behaviour can be picked up. In Scotland they aren’t even looking. So is all lost in Scotland?

Not quite. The Scots have some older targets up their sleeve: maximum waiting times for each stage along the pathway. A maximum 12 week wait for outpatients, 9 weeks for inpatients and daycases, no exceptions.

How does this matter? 12 + 9 = 21 weeks, which is longer than the new 18 week target. Aren’t these targets redundant? No, because these waiting times are monitored for patients still waiting (as well as those seen or admitted). So if any Trust tried to “game” the 18-week RTT targets by titrating their long-waiters, they would run into the stage-of-treatment targets a few short weeks later.

There are some potential loopholes still. Trusts could conceivably abuse the targets by holding patients in follow-up loops or excessive diagnostic waiting lists, and then titrating them through the 18 week target. It would have been better in Scotland to monitor the 18-week target in terms of patients still waiting, instead of those admitted.

But perhaps Scotland has achieved something that England could learn from? If English politics rule out a change in the 18-week target, then perhaps a Scottish-style backstop could be introduced? The 6-week diagnostic target sets the precedent for stage-of-treatment targets based on a census of patients still waiting. Could we have a backstop for other stages too?

This post first appeared at HSJ blogs