NHS gooroo blog

Archive for August, 2011

Yesterday I showed how NHS waiting times are reported upside-down: when waiting times get better, the headlines scream disaster. Today I am going to move beyond finding fault with journalists. There are, after all, plenty of things wrong in the real world of NHS waiting times, and once we start focusing on the right numbers there are lots of reasons to hold the government and the NHS to account.

So here are the stories that might be reported more. They have not been entirely ignored in the past, but neither have they been given the prominence they deserve.

1) Long waiting times

There are plenty of hospitals around England with very long waiting times. In some cases, patients are still waiting more than a year after being referred by their GPs.

This map (click it for the interactive version) shows the top 100 waiting time pressures, by hospital and specialty. Because it’s based on the so-called “incomplete pathways” it shows long-waiters who are still on the waiting list.

The Guardian gave an excellent report on the Trust with the worst pressures in their piece on the June waiting time figures. There is plenty of scope for holding the NHS to account for these long-waits, once we start focusing on incomplete pathways instead of admissions.

2) Long waiting times that are not being dealt with

What is much worse is that the NHS is actually being forced to make patients wait instead of treating them.

It isn’t necessarily the hospital’s fault if its waiting times have grown. If referrals are pouring in, but the Trust isn’t being paid to treat them all, then waiting lists will grow and so will waiting times. This supply/demand balance is a well-worn subject that I won’t go into here.

What I do want to highlight is that different hospitals respond to this problem in different ways. Some do their best to fix the problem, by treating as many of the longest-waiters as possible and making sure no patient is left waiting indefinitely. But others don’t do this, preferring instead to let their waiting list grow a long tail of abandoned patients. Why?

It is hard to blame the hospitals. They know that if they treat their long-waiters then they will fail against the headline waiting times target. In upside-down fashion this target limits, to one patient in ten, the number of over-18-week waiters they are allowed to treat. Under the standard NHS contract they can be fined heavily if they do not comply. This admission-based target is a serious policy error that the current Government should be taken to task over (unfortunately they inherited it from the current Opposition, so expect no challenge from that direction).

So where are these hospitals, who “achieve the target” while long-waiters languish on their waiting lists? Here is an interactive map that picks them out; it shows those hospital specialties where 90 per cent of admissions waited under 18 weeks, but more than 10 per cent of incomplete pathways (i.e. of the waiting list) had waited over 22 weeks.

3) Median waiting time targets that drive up long-waits

The Government is trying to push the emphasis away from long-waiters onto “average” (by which they mean “median”) waiting times for admitted patients. In this case the problem is not the focus on admitted patients, but the way that medians are being targeted.

The main waiting list specialties are surgical specialties where the majority of patients are “routines” (not clinically urgent). If you took all the admitted patients and sorted them in order of waiting times, then the middle (i.e. median) patient would be a routine patient. So would all the patients who waited longer than the median, including the longest-waiting patient and the 95th centile patient.

Routine patients generally have no clinical reason to jump the queue on other routine patients. So natural fairness (as well as good waiting list management) says you should admit routine patients on a first-come-first-served basis as far as possible. Do that, and all routine patients will experience roughly the same waiting time, including the median and 95th centile patients.

So in a well-managed waiting list, the median and 95th centile waiting times should be quite close together. If they aren’t, that is a sign that many routine patients are jumping the queue. And we know that queue-jumping by some people leads to longer waiting times for others. So if you lower the median waiting time for admitted patients, as the Government wishes, then the maximum wait will go up: another example of an upside-down Government target having unintended consequences.

The Government’s thinking on median waiting times sets the clock back to the 1990s, when the (Conservative) Government used to cheer the high number of patients admitted within 3 months, at the same time as others were waiting up to 2 years. I thought we had moved on from those days, but sadly it seems we must fight this battle all over again.

4) Delayed urgent patients

Sometimes hospitals can be under such pressure to achieve 18 weeks that they find it difficult to admit urgent patients quickly enough. This can happen, for instance, if they are using PTLs (a common management technique for achieving 18 weeks, currently being promoted by the Department of Health’s Intensive Support Teams). Delaying urgent patients is a serious matter because it causes a clinical risk to them.

It isn’t possible, from the published RTT waiting times data, to tell definitively whether any hospital is in this position. We know that the proportion of patients treated quickly varies from Trust to Trust. We also know that the proportion treated quickly tends to be lower if the hospital is struggling with 18 weeks. So I indicate, on our detailed waiting time reports for each hospital and specialty, whether the proportion being treated quickly is on the low side compared with other hospitals, but we have no way of knowing from these figures whether urgent patients are actually being delayed or not.

Delaying urgent patients is directly addressed through the cancer waiting times targets set by the government. But not all urgent patients have cancer, and cancer delays can happen by cancelling follow-up appointments as well as by delaying the first clinic appointment. So it is worth being alert to the possibility that urgent patients could be delayed when investigating services with severe waiting time pressures.

Conclusion

There is plenty to get our teeth into, once we all stop distracting ourselves with irrelevant figures and upside-down targets. There are plenty of long-waiting patients still on the waiting list, plenty of policy errors, plenty of potential risks to patients to be reported and challenged. The best journalists are already picking these up. Now let’s give them the fuller attention they deserve.

This post first appeared at HSJ blogs.

Waiting lists grew 61% in the past year

said the Guardian, reporting that “11,857 people in June had waited half a year to receive treatment, up from 7,360 in June 2010″.

Waiting times continue to soar

said the Mirror, reporting that “The number of people on treatment lists for more than 18 weeks increased by 9,013 to 31,483 in the 12 months to June”.

NHS waiting lists rise

said the opposition Labour Party, adding that “Compared with last year, a third more patients are waiting longer than 18 weeks for hospital treatment and the situation is getting worse by the month. With the figures also showing a doubling since May 2010 in the number of patients waiting over a year for treatment, it is clear that people can’t trust David Cameron to keep his NHS promises.”

Which is all rather different from my assessment: “Waiting times steady in June” (which admittedly is not a very exciting headline). We’re all working off the same data release, so why the different messages?

The explanation is simple. I was looking at patients still waiting at the end of June (the so-called “incomplete pathways”), and they were looking at patients who got treated during June (specifically, the so-called “adjusted admitted pathways”). The result: good gets reported as bad.

Let’s take the Guardian’s numbers first. They are working off the data in this spreadsheet, and 11,857 is the number of patients admitted during June 2011 who had waited more than 26 weeks (on an adjusted basis, as with all the other admission-based figures I will quote here). They are comparing this with the number admitted in June 2010 who had waited more than 26 weeks, which was indeed 7,360.

Yes, it’s an increase of 61 per cent. But an increase in what? Not in the waiting list: that shrank slightly from 2,569,098 to 2,551,779 (as you can see from DH’s “incomplete pathways” data in this spreadsheet). Not even in the number of over-six-month waiters on the waiting list: that fell from 95,814 in June 2010 to 93,123 in June 2011.

No, the increase of 61 per cent was in the number of over-26-week waiters being admitted for treatment. But treating long-waiters is a good thing, right? It’s certainly better than the alternative: not treating them, and leaving them to wait even longer. So when the NHS treats long-waiting patients, this is somehow being reported as a disaster.

This is all starting to look topsy-turvy.

Moving on the Mirror, you can probably guess where they got their figures from. That’s right: 31,483 is the number of patients admitted during June 2011 who had waited more than 18 weeks (on an adjusted basis), taken from the same DH spreadsheet the Guardian were using. This was an increase of 9,043 (not quite the figure the Mirror worked out) from 22,440 in June 2010.

Again the Mirror are reporting an increase in the number of long-waiters being treated, not an increase in those still waiting. In fact the number of over-18-week waiters on the waiting list did go up, slightly, from 221,588 to 226,466 (an increase of 2.2 per cent). But that isn’t what they reported.

Moving on to Labour, we have already covered their first statistic, which is the same one used by the Mirror. Their second (“a doubling since May 2010 in the number of patients waiting over a year for treatment”) is, yet again, based on an increase in the number of over-52-week waiters who were admitted during June (from 430 in June 2010 to 718 in June 2011; an increase of 67 per cent, rather than a doubling). Again, surely it is a good thing if the NHS treats its longest-waiting patients?

If they had looked at patients who were still waiting, what would they have seen? The number of over-52-week waiters on the waiting list fell from 18,221 in June 2010 to 13,259 in June 2011, an improvement of 27 per cent. (In fact the June 2011 figure would have been the best ever recorded in the NHS, if Kingston Hospital had not ended its absence from the data series by landing 2,314 over-52-week waiters onto the national waiting list.)

Good is reported as bad, improvements as disasters, and then when patients are kept waiting the headlines fall silent; all because people are watching the wrong numbers. I think this is a cause for shame, and I’ll be coming back to this theme in future posts.

This post first appeared at HSJ blogs.

Waiting times across England

Waiting times held steady in June, and continue to follow the seasonal trend. Ten per cent of the waiting list was over 17.2 weeks, the same as in May; and 90.2 per cent of admitted patients were treated within 18 weeks (compared with 90.8 per cent in May). In the chart below, the dotted line shows the waiting list (the so-called incomplete pathways) at the end of June, and the solid line shows patients who were admitted for treatment during June.

The total number of patients on the waiting list is also following the seasonal pattern of the last couple of years (as the next chart shows). If this carries on, it might mean a repeat of last year’s winter backlog (the hump in the dotted line in the chart above) which was followed by breaches of the headline admission-based target as the NHS recovered from it in the spring.

The total list size levelled-off in June as a result of increased elective activity (see chart below). This increase in admissions is in line with the pattern of previous years; there are two bank holidays in May but none in June. It is worth noticing that there is no evidence here of elective activity slowing down this year as a result of any financial constraints.

For more detail on the English figures you can download our RTT waiting times fact checker, which contains complete time series for all the main English waiting time measures, here:

RTT waiting time fact checker.xls

 

Waiting times by Trust

As always, the national picture conceals huge variations from Trust to Trust. In the following chart, each English Trust is represented by two dots: a red one and a blue one. The red dots show how long the top ten per cent of the waiting list is still waiting at the end of June (incomplete pathways). The blue dots show how long the top ten per cent of patients admitted during June had waited before they were treated (adjusted admitted pathways).

You might expect that, if a Trust had lots of long-waiting patients, then it would admit lots of long-waiting patients in an effort to clear the backlog. But one of the interesting things about this chart is it shows that this doesn’t always happen. If you look at the right hand side of the chart, where you’ll find the Trusts with the longest waiting times, you can see plenty of blue dots under the 18-week line. Those Trusts are “achieving the target” even though they have plenty of long-waiting patients on their waiting lists; so long as they only admit one long-waiter in every ten admissions, they will achieve the headline “90 per cent admitted within 18 weeks” target.

The proportion of Trusts, where at least 90 per cent of patients on the waiting list are under 18 weeks, has improved slightly since May. At 70 per cent, this is the best since July 2010. The next chart shows the trend; this chart is related to the one above because it tracks the point where the red line (in the chart above) crosses 18 weeks.

Looking across England, which Trusts have the greatest waiting time pressures? Based on the waiting list (incomplete pathways) the top 20 is:

Trust	Position in June	Top 10% waiting over	Change	Position in May
Kingston Hospital NHS Trust	#1	more than 52 weeks		did not submit data
Wirral University Teaching Hospital NHS Foundation Trust	#2	32.0 weeks	up 2	from #4
Great Ormond Street Hospital for Children NHS Trust	#3	31.3 weeks	down 1	from #2
Surrey and Sussex Healthcare NHS Trust	#4	30.3 weeks	up 3	from #7
University College London Hospitals NHS Foundation Trust	#5	29.0 weeks	down 4	from #1
Shrewsbury and Telford Hospital NHS Trust	#6	26.2 weeks	down 3	from #3
Royal Devon and Exeter NHS Foundation Trust	#7	25.7 weeks	down 1	from #6
United Lincolnshire Hospitals NHS Trust	#8	23.0 weeks	up 14	from #22
The Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust	#9	23.0 weeks	up 91	from #100
Heatherwood and Wexham Park Hospitals NHS Foundation Trust	#10	22.9 weeks	up 11	from #21
Newham University Hospital NHS Trust	#11	22.7 weeks	up 7	from #18
Imperial College Healthcare NHS Trust	#12	21.8 weeks	up 11	from #23
Pennine Acute Hospitals NHS Trust	#13	21.6 weeks	up 2	from #15
Derby Hospitals NHS Foundation Trust	#14	21.5 weeks	up 5	from #19
Yeovil District Hospital NHS Foundation Trust	#15	21.4 weeks	up 20	from #35
Guy’s and St Thomas’ NHS Foundation Trust	#16	21.4 weeks	up 12	from #28
The Whittington Hospital NHS Trust	#17	21.3 weeks	down 4	from #13
Barking, Havering and Redbridge University Hospitals NHS Trust	#18	21.2 weeks	down 9	from #9
St Helens and Knowsley Hospitals NHS Trust	#19	21.1 weeks	down 8	from #11
South London Healthcare NHS Trust	#20	21.0 weeks	down 8	from #12

Kingston have gone straight in at #1 having failed to submit incomplete pathways data since March. I don’t have any local knowledge of what has been happening there, but I know that a few journalists are on the trail (after I tweeted their figures this morning). So more details will probably emerge later today.

You can find full details of the position at each Trust, including time trends, via the interactive maps below: click on a pin to get a balloon showing a summary of any Trust’s data, and then click on the Trust name in the balloon to get a full analysis with charts.

There are separate maps for each specialty (all maps based on incomplete pathways):

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

To find the greatest waiting time pressures around England, in any specialty, click the map below. It shows the 100 services where the top 10 per cent of the waiting list is waiting the longest.

 

If you have a particular Trust in mind, you can directly look up its detailed reports here.

Sadly, all the above analysis comes with a caveat: in many parts of England there are restrictions on hospital referrals that have the effect of blocking or holding up patients before they arrive on the hospital waiting list. Those patients are not included in the reported figures, and so they are missing from this analysis.

The July 2011 waiting time figures are due out at 9.30am on Thursday 15th September.

This post first appeared at HSJ blogs.

As British schools broke up and everyone headed off for their summer holidays, the Co-operation and Competition Panel (CCP) published their final report on Any Willing Provider. One passage that caught journalists’ and commentators’  eyes was this (para. 91):

The imposition of minimum uniform waiting times at providers [by PCTs] also appears reasonably widespread.

The CCP reported that PCTs claimed two benefits of minimum waiting times.

• more equitable treatment for patients across different providers;
• reduced expenditure for taxpayers.

The CCP criticised the first as “an unfortunate levelling-down”, and the second as a “one-off benefit that cannot be repeated”. In response to the argument that longer waits can save money as patients remove themselves from the list, they said (in a much-reported footnote to page 29):

We understand that patients will “remove themselves from the waiting list” either by dying or by paying for their own treatment at private sector providers, and that there is a relationship between the self-pay market in private healthcare and the length of waiting lists in the NHS. However, research suggests that the effect of increasing waiting times at all hospitals is unlikely to be significant. A 10% reduction in waiting times is associated with an increase in demand of between 1.35% and 2.35%. Assuming increases and decreases in waiting times have a similar effect, it is likely that an increase in waiting times will have a small impact on overall demand for services.

Actually a 2 per cent fall in elective demand sounds like a very useful saving to pocket, in return for a small increase in waiting times from (say) 15 weeks to 16.5 weeks. Unfortunately the CCP do not provide a reference for their statement that “research suggests” this. There is other evidence that waiting times over 10 weeks may deter patients: RAND Europe, City University  and the King’s Fund surveyed patients’ attitudes to waiting times in 2006, and found (in para. 5.3.2):

For waiting times of 8 weeks or less, a change in waiting time is valued as zero. That is to say, on average there is no benefit from reducing the waiting time from referral to treatment below 8 weeks. Once the waiting time reaches 10 weeks, there is, however, a step change where the increases in waiting time are valued negatively (and significantly different from zero). It can be seen that the rate of change is relatively constant, implying that for waits of 10 weeks and above the valuation of waiting time increases approximately linearly.

In other words, patients are unfazed by waiting times under 10 weeks. But when waits are over 10 weeks, every extra week adds the same amount of extra disincentive. Whether this disincentive actually translates into reduced demand, unfortunately, is not something that RAND et al come to any clear conclusion about.

So what about the argument, advanced by the CCP and others, that it is pointless trying to save money by lengthening waiting times, because you only get the savings once? I think most commissioners would respond (as some did to the CCP) that once is better than never, and that if the requirement is 18 weeks then why divert scarce resources towards even-shorter waits for the least-sick patients in the system?

But I think minimum waiting times are objectionable for another reason: they create hopelessness.

Waiting times and waiting lists are not simply the balance of activity and the demand for healthcare. A fair amount of NHS activity is devoted to patients who are stuck in follow-up loops, who attend clinics when the result of their diagnostic test is not in the notes, who are referred to the wrong specialist, or who keep coming back as emergencies because their long term condition is not being managed.

If clinicians and managers can achieve system improvements that drive out this “failure demand” then waiting lists and times would largely disappear in those services. But no clinician or manager is going to bother, if all the benefits of system improvement are going to be instantly confiscated by a minimum waiting time requirement, bluntly imposed by the commissioner.

payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed

For this reason alone, minimum waiting times should not be an operational requirement; payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed.

Having said that, it is surely unrealistic to expect commissioners and trusts to plan activity based on (say) 10 week waits across the board, when their figures say that only 16 weeks is affordable? Or to continue to fund 8 week waits in General Surgery when Orthopaedics is struggling at 22 weeks?

To be sure, planning activity and capacity on the basis of 18 weeks, when the service concerned is currently achieving 10 weeks, is a step backwards. More than that, it is a shame, because those short waits were hard-won, and there is always the worry that letting patients wait is the easy way out for the NHS.

But times are tight. There is a difference between, on the one hand, commissioners using 18 weeks as their planning assumption, and on the other hand imposing 15-week minimum waiting times operationally on a patient by patient basis.

Good planning protects urgent patients

It is worth remembering that good planning, based on realistic assumptions about what is possible with waiting time management, also protects hard-pressed services by releasing resources for them. When long-wait targets are being aggressively pursued, this extra resource may be essential to stop urgent patients being delayed.

This post first appeared at HSJ blogs

PTLs have been around since the early 2000s as a tried-and-trusted way of achieving waiting time targets.

What are they? The name doesn’t tell you much (depending on who you ask, PTL stands for Patient/Primary Targeted/Targeting/Tracking/Treatment List) but the concept is easy enough to explain:

Pretend it’s the 1st of February. In 4 weeks time, on the 1st of March, you want to have no patients waiting longer than 18 weeks since referral. All the patients who could possibly breach that target have already waited over 14 weeks. You know who they are, and the “PTL” is the list of their names. If you book everybody on the PTL in for treatment during February, then (so long as you don’t cancel any) you are guaranteed to achieve the target. Simple.

But this deceptively simple approach creates problems of its own.

Firstly, if you have a serious waiting time problem, then it is very difficult to find slots for all those patients. You might end up using slots that should really be kept aside for urgent patients who haven’t arrived yet. If urgent patients end up being delayed as a result, then you have created a clinical risk that could result in patients being harmed. This is a serious matter which a good booking system should be designed to avoid.

Secondly, when booking the PTL, your main concern is to find slots in February. Exactly which patient goes into which slot may be considered less important. But if you book routine patients out of order then the maximum waiting time goes up: those lucky patients who squeeze in for treatment at 14 and 15 weeks are jumping the queue on those waiting longer, and we know that queue-jumping pushes up maximum waiting times. So at next week’s meeting you will have more difficulty clearing your PTL, even though your underlying waiting time pressures have not changed.

PTLs manage long-waits in batches and at the margins

These problems arise because you are managing your long-wait problem in batches and at the margins, and your actions have unintended consequences for the rest of the system. It would be better to manage the whole system continuously in the right way, and so achieve the best possible waiting times safely and consistently.

If this holistic approach means that you can achieve 12 weeks, then you will. (You might not have realised it was possible using PTLs.) If the best you can achieve is 20 weeks, then you have a problem; but your planning and monitoring systems should have picked up this pressure already and pointed to solutions for relieving it (perhaps by moving resources from those services that can achieve 12 weeks).

What if your waiting list is just too huge to achieve 18 weeks safely and continuously? Then your problem is not so much waiting list management, but a mismatch between supply and demand that needs to be tackled together with commissioners.

While you’re dealing with that, you need to ask yourself how you want to fail in the meantime. You are faced with three main choices:

1. carry on treating routine patients in turn even if they all wait over 18 weeks;
2. drip-feed your long-waits through the system so that at least you’re achieving the headline target (90% of admissions within 18 weeks) while the backlog gets worse; or
3. squeeze so hard that urgent patients end up being delayed.

The first is the high moral ground, and the holistic approach; the second is understandable; the third is surely indefensible. PTLs, unfortunately, are most likely to lead you towards the third.

This post first appeared at HSJ blogs