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Archive for October, 2011

those who have already waited over 18 weeks must not be forgotten

said the Department of Health, following the release of last month’s RTT waiting times. Quite right too.

When patients are waiting very long times for treatment, it is easy to lose track of their needs. A jumble of data errors builds up, so that we don’t know which patients really do need treatment, and which don’t.

We still have 20,000 patients waiting over a year in England, so these problems are with us now. But things were much worse in the past. Back in 1992 patients were waiting more than 2 years, just for the inpatient stage of their treatment.

A national task force was formed, and while they were clearing the backlog they came across all kinds of things, some comical errors, but some awful tragedies as well. Here is an extract from a report they put together after visiting one hospital (with thanks to Anthony McKeever, the head of that task force, for providing it).

 

EXAMPLES OF PROBLEMS/ANOMALIES IDENTIFIED FROM A WAITING LIST PRINT OUT PRODUCED ON 10/3/92.

If they are to be taken literally, and are shown upon detailed enquiry to be accurate, the lists supplied to us reflect clinical problems and mismanagement over a number of years. Examples relevant in this context are:

> A lady apparently aged 117 listed nine years ago for a breast reduction.

> A man listed in 1987 who was offered an opportunity for an operation but was cancelled because of “no theatre time” and who has still not been offered another date.

> A girl listed as an infant because of a haemangiona (malformation of the blood vessels) on her wrist who is still waiting for the operation to correct it although she is now in her teens.

> A man whose need for an operation was confirmed after 10 years on the list – and who is still waiting for it two years later.

> A young girl listed for a rhinoplasty at aged 15 – who is now aged 28.

> A little girl listed for a scar on her right upper lip listed at 3 years of age, who is now 13 years old.

> A lady who is 48 years old listed 14 years ago for a revision of a scar.

> A lady who in 1980 was listed as requiring an operation to restore a congenital abnormality of the right breast who is still awaiting her operation 14 years later.

> A six year waiter identified as needing a further operation on his right ear to correct an earlier one (which had been unsuccessful).

 

The extreme multi-year waits should, thankfully, be well behind us now. But with over-one-year waiters still on the waiting list, there remains the risk of personal tragedies like those above. Until the longest-waiters have all been verified, and where necessary treated, that risk and uncertainty will remain.

The NHS fended off its waiting time pressures in August, providing some much-needed breathing space as winter approaches. The total waiting list was down 1.5% compared with August 2010, as were other waiting list-based indicators across the board: over-18-week waiters were down 6.8%, over-26-weeks down 9.2%, and over-52-weeks down 4.4%.

By a bizarre coincidence, the number of over-one-year waiters was exactly the same as in the previous month, at 19,939. But that’s still 19,939 too many. The NHS admits 270,000 under-18-week waiters every month, so why does it not treat these very-long-waiters? This month we are raising the profile of these over-one-year waiters, and you’ll find more details about them both in our interactive maps and in the detailed Trust-specialty reports.

The Government’s preferred measures don’t focus on the waiting list, however, but focus instead on patients who were lucky enough to be treated during the month. Both of the NHS Constitution targets were met in August, and the official statistical press notice and all the data are available here.

For a comprehensive collection of referral-to-treatment (RTT) waiting times measures with time trends, you can download our waiting times fact checker here:

Gooroo-RTT-waiting-times-fact-checker.xls

England-wide picture

Long-wait pressures on the waiting list recovered slightly in August, with 90 per cent of patients on the waiting list below 17.5 weeks (improved slightly from 17.6 weeks in July, and well below the 17.9 weeks of a year earlier). The chart below shows the time trend for this measure (dotted line). For comparison with the NHS Constitution targets, the waiting time enjoyed by 90 per cent of admissions is shown as a solid line.

This improvement was helped along by the relatively high level of admissions in August, as a result of the way the weekends fell this year, as shown in the following chart:

As a result the number of admissions was the highest of any August in recent years:

Not that this made any particular difference to the overall size of the waiting list, which continued to shadow last year’s trend (though slightly improved):

Drilling down to specialty level, Neurosurgery continues to cause concern at a national level, and General Surgery edged a little closer to becoming the new Orthopaedics in terms of big-specialty waiting times trouble. All other specialties were level or slightly improved.

 

Trust-level picture

In July, only two Trusts (St George’s and Kingston) reported more than 1,000 over-one-year waiters on their waiting lists. In August that number trebled, with Guy’s and St Thomas’, RUH Bath, Sheffield, and South London all joining the club.

Over-one-year waiters are also found in smaller numbers all over the country, as this interactive map shows.

If your Trust has over-one-year waiters on the waiting list, there may be a belief within your organisation that those patients aren’t really in need of treatment: they’re probably miscoded watchful-waiters, or not been removed, or something. But can you put your hand on your heart, and swear that not a single one of them needs an operation? I didn’t think so. And that’s why it’s important not to lose sight of these patients, and why we’re raising their profile again today.

Returning to the rest of the waiting list, we continue to see the perverse effects of the Government’s preferred waiting times measures, with plenty of Trusts achieving the “90% of admissions within 18 weeks” target, despite having plenty of much longer waiters.

In the following chart, each Trust is represented by a pair of dots. The red dot shows the waiting time that 90 per cent of the waiting list falls below. The blue dot shows the waiting time that 90 per cent of admitted patients (i.e. admitted during August and no longer waiting) had waited below. If a Trust has high waiting time pressures (i.e. a high red dot), you might expect them to bring those pressures under control by admitting their long-waiters, and so their blue dot would be high too. Unfortunately the Government’s preferred waiting times targets punish Trusts for having high blue dots, so they try to keep them below the 18-week line, which is why lots of Trusts have high red dots but low blue dots. The targets get in the way of Trusts dealing with their waiting time pressures, which is unfair on the Trusts, bad for patients, and needs sorting out. Keep passing the message on, we’ll get there one day.

The point where the red dots cross the 18 week line is interesting, because it shows the balance of Trusts with and without high underlying waiting times pressures. This proportion changes over time, and in August it fell back but only very slightly:

The Trusts with the greatest waiting time pressures, which are those to the far right of the blue/red dot chart above, are shown here as a “top twenty”. As you can see, several Trusts are achieving the “90 per cent within 18 weeks” target even though they have high proportions of long-waiters (and are even making some patients wait more than a year).

Trust	Position in August	Change	10% of waiting list exceeds	Over-one-year waiters on list	90% admitted within 18 weeks?
Kingston Hospital NHS Trust	#1	(no change)	52+ weeks	3,271	target met
St George’s Healthcare NHS Trust	#2	(no change)	52+ weeks	3,432	no (27.7 weeks)
Wirral University Teaching Hospital NHS Foundation Trust	#3	(no change)	39.2 weeks	981	no (25.1 weeks)
United Lincolnshire Hospitals NHS Trust	#4	(up 4 from #8)	28.6 weeks	726	no (20.6 weeks)
Shrewsbury and Telford Hospital NHS Trust	#5	(no change)	28.5 weeks	317	no (38.8 weeks)
Surrey and Sussex Healthcare NHS Trust	#6	(no change)	28.2 weeks	296	no (34.7 weeks)
Guy’s and St Thomas’ NHS Foundation Trust	#7	(up 5 from #12)	26.5 weeks	1,185	no (21.9 weeks)
Sheffield Teaching Hospitals NHS Foundation Trust	#8	(up 5 from #13)	24.1 weeks	1,115	target met
University College London Hospitals NHS Foundation Trust	#9	(down 5 from #4)	23.7 weeks	239	target met
South London Healthcare NHS Trust	#10	(down 1 from #9)	23.6 weeks	1,008	no (23.8 weeks)
South Warwickshire NHS Foundation Trust	#11	(up 6 from #17)	23.3 weeks	26	target met
Yeovil District Hospital NHS Foundation Trust	#12	(down 1 from #11)	23.0 weeks	2	target met
Royal United Hospital Bath NHS Trust	#13	(up 60 from #73)	23.0 weeks	1,169	no (18.6 weeks)
Buckinghamshire Healthcare NHS Trust	#14	(up 13 from #27)	23.0 weeks	0	no (20.9 weeks)
Derby Hospitals NHS Foundation Trust	#15	(no change)	22.8 weeks	0	no (19.7 weeks)
St Helens and Knowsley Hospitals NHS Trust	#16	(down 2 from #14)	22.8 weeks	187	no (37.4 weeks)
Taunton and Somerset NHS Foundation Trust	#17	(up 7 from #24)	22.2 weeks	0	target met
Imperial College Healthcare NHS Trust	#18	(up 4 from #22)	22.2 weeks	127	no (18.1 weeks)
Warrington and Halton Hospitals NHS Foundation Trust	#19	(down 3 from #16)	21.9 weeks	145	target met
South Tyneside NHS Foundation Trust	#20	(up 1 from #21)	21.7 weeks	0	target met

For full details of waiting times and over-one-year waiters at Trusts and specialties across England, these interactive maps show where the pressures are. Click a specialty to see the map, then click the pins to get numbers for each Trust, and you can even click the Trust name to get a very detailed report with comparisons and time trends. (Or you can go straight to the detailed reports here.)

All the specialty maps are here (all maps based on incomplete pathways):

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

For example, here is the map for General Surgery:

All the above analysis comes with a caveat: in 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 September 2011 RTT waiting time figures are due out at 9.30am on Thursday 17 November 2011.

This post first appeared at HSJ blogs

On 3rd October, Andrew Neil did an extended interview with Andrew Lansley. Waiting times cropped up (at 19m24s), and a throwaway remark by Andrew Lansley revealed something very interesting. He said:

The first point you made was, waiting lists – in fact, what I think you meant, waiting times, but you said waiting lists have gone up, they haven’t…

There is evidently a distinction in Andrew Lansley’s mind between waiting lists and waiting times. But what is it?

Back in the 1980s we all talked about waiting lists, as in “there are this many patients on the waiting list, up from that many”. Then people quite rightly observed that if you are a patient on the waiting list, you don’t really care how many other patients there are: you just want to know when you are going to be treated. You fear that you might wait as long as some of those poor patients you read about in the newspapers, who wait for many years and sometimes even die waiting.

Because of those fears, maximum waiting times came to the fore. In the early 1990s the 2-year maximum wait for inpatients and daycases was achieved. Then 18 months. And the NHS was ready to push for a 12 month maximum inpatient wait when the Conservatives lost power in 1997. At the same time there was also a lot of counterproductive bragging by the Department of Health about how many patients were being treated within 3 months (in other words, how much unjustified queue-jumping there was), but public attention was very much focused on those patients who were waiting the longest.

The incoming Labour Government achieved great things on NHS waiting times: firstly by monitoring the whole referral-to-treatment pathway instead of selected stages (no mean feat in itself), and then by improving beyond recognition the waiting times for that whole pathway. But at the same time, there was a shift in the meaning of “waiting times”, and that is the shift revealed in Andrew Lansley’s remark.

Nowadays when politicians talk about “waiting times”, most journalists (and as a result, most people) think they are talking about waiting lists. We know this because of the way the headlines are written. But they aren’t talking about waiting lists at all. The statistics that Andrew Lansley quoted in the interview, and indeed the statistics that Andrew Neil threw at him, were all about admitted patients, not patients still on the waiting list.

So when Andrew Lansley said that average waiting times have come down, he was referring only to those patients lucky enough to have received treatment. They are not necessarily representative of those still waiting, nor is the median very enlightening as a statistic. And if average admitted waits come down, without a corresponding reduction in the number of patients on the waiting list, it isn’t good news either.

Likewise, when Andrew Neil said that the number of over-18-week waiters has gone up by 20 per cent, he wasn’t talking about the waiting list. He was quoting figures that show a rise in long-waiting patients being admitted for treatment. And that’s a good thing, actually, because it means the NHS is clearing its long-wait backlog more quickly. Amazingly, Andrew Lansley didn’t pick this up and say that it shows just how marvellous everything is. (And neither does David Cameron when Ed Miliband levels similar charges.)

So it seems that the term “waiting times” has been twisted into some kind of opposite to “waiting list”. It refers to patients who have been treated, and aren’t on the waiting list any more. All the statistics have been twisted around as well. And everybody has fallen into the trap.

That explains why journalists pick statistics that are actually good news, and present them as bad news. And why Her Majesty’s Opposition does the same. Government ministers, in their ignorance, fight back with statistics that are actually bad news, and present them as good news. The public just nods along, always fearful that things are getting worse, because they are getting no useful information from anybody.

How can we break this cycle? Any one of the players could do it: Government, Opposition, or journalists. Or indeed the Department of Health, who after all give Government Ministers their briefings. Anyone want to go first?

This post first appeared at HSJ blogs