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Archive for December, 2011

What on earth is going on with the Government’s referral-to-treatment waiting times targets?

In the last few weeks we have heard great things from them, showing that they now understand the problems created by the current target regime and want to move forwards. For instance the new Operating Framework says:

The operational standards of 90 per cent for admitted and 95 per cent for non-admitted completed waits as set out in the NHS Constitution remain. In order to sustain the delivery of these standards, trusts will need to ensure that 92 per cent of patients on an incomplete pathway should have been waiting no more than 18 weeks. The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.

Operating Framework 2012/13, para 2.31

The new target is very welcome and in a perfect world it would have completely replaced the old targets (which punish Trusts for treating long-waiting patients). But abandoning the old targets would have required amendments to legislation, and invited political criticism that the Government was letting go of waiting times, so it isn’t entirely surprising that they have been retained.

This new, better direction of travel was reinforced in the latest edition of The Quarter. It said:

In addition to sustaining and improving performance against the NHS Constitution operational standards, the NHS must also ensure that those still waiting longer than 18 weeks are treated as quickly as possible. As set out in the NHS Operating Framework for 2012/13, from next year trusts will need to ensure that 92 percent of patients still waiting for treatment (also known as incomplete pathways) have been waiting no more than 18 weeks. Therefore, the NHS needs to take action to treat patients still waiting over 18 weeks after referral, for reasons other than choice or clinical exception.

In particular some trusts are currently reporting an unacceptable number of patients still waiting more than a year for treatment after referral.

At the end of September 2011, five trusts were responsible for around half of those people still waiting more than a year for treatment (see figure 12). These trusts, and any other trusts that are reporting patients still waiting more than a year for treatment after referral, must take action to understand the reasons behind these long waits and treat any patients still waiting as quickly as possible.

The Quarter: Quarter 2 2011/12, p.11

Amen to all that.

Which brings us to the latest big publication, which in many ways is the most important. The NHS Standard Contract lays out in detail the precise targets and penalties under which the NHS will operate in the coming financial year. Now that the Government has shown that it both understands the problems created by the old waiting time targets, and has shown willingness to change its approach in helpful ways, I would have expected the new Contract to:

1. pay lip service to the old treatment-based targets and the regulations underpinning them around the NHS Constitution, but
2. remove the financial penalties that actually punished Trusts for treating too many long-waiting patients, and
3. replace them with a new penalty regime that punished Trusts for having too many long-waiters on the waiting list, in line with the new target.

(I’m not saying that creating a new penalty regime is necessarily the best way of going about this, just that it would be in keeping with the traditions of NHS management.)

So what does the Contract actually say? Here are the relevant paragraphs in all their glory (my emphasis below):

Subject to Clause 43.6, if in any month the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 (Nationally Specified Events) for any specialty, then the Commissioners shall deduct for each such specialty an amount calculated in accordance with Section B Part 8.4 and weighted in accordance with Clause 43.5, from any payments to be made to the Provider under this Agreement.

2012/13 NHS Standard Contract, Section E, clause 43.4

Technical Guidance Reference: PHQ19-20

Nationally Specified Event: Percentage of patients seen within 18 weeks in respect of Consultant-led Services to which the 19 Weeks Referral-To-Treatment Standard applies

Threshold: For admitted 90% and over And For non-admitted 95% and over

Method of Measurement: Review of monthly report under Clause 39.1 of the Core Legal Clauses

Consequence per breach: As set out in Clause 43.4 of the Core Legal Clauses and Section B Part 8.4

 2012/13 NHS Standard Contract, Section B, Part 8.2 on p.16

Percentage by which the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 for each specialty (in respect of Consultant-led Services to which the 18 Weeks Referral-to-Treatment Standard applies) [heads a table column, with bands running from 0 to over 10 per cent]

Percentage of the revenue, derived from the provision of the (underachieved) specialty in the month of the underachievement, to be deducted under Clause 43.4 subject to the cap of 5% of the Contract Month Elective Care 18 Weeks Revenue pursuant to Clause 43.6 of the Core Legal Clauses [heads a column with penalties running from 0.5 to 5 per cent]

 2012/13 NHS Standard Contract, Section B, Part 8.4 on p.26

Lots about the old admitted and non-admitted targets, then. But where is the incomplete pathways target? Nowhere.

What will this do to waiting times? It fundamentally undermines the Government’s stated intention to reduce the number of patients “forgotten” on English waiting lists. For all the Government’s fine words, the new Contract retains the penalties that punish Trusts for treating lots of long-waiting patients, and creates no new incentives for them to achieve short waits on the waiting list.

When money is tight, and Trusts have a statutory duty to balance the books, which of fine exhortations and financial penalties is going to weigh more heavily on peoples’ minds? (That was a rhetorical question.)

Personally, I am baffled. Why did the Department of Health not carry the new target through from the Operating Framework to the Contract? I simply do not understand it.

So here’s a little suggestion to DH. While you are correcting the typo that refers to a 19-week target, why not take this opportunity to change the penalty regime over to “92 per cent of incomplete pathways within 18 weeks”? If everyone’s off over Christmas, I’ll even help with the drafting.

Have a lovely festive break.

[Update: The NHS Standard Contract, Section B, Part 8.2 was amended by DH a few hours after this post was first published at HSJ blogs. They fixed the 19 week typo, but not the target.]

Where are the longest waits? What are waiting times like in your local NHS? How difficult is the new waiting time target? Here are some maps to help you find the answers.

All the maps are interactive: you can zoom and scroll, click on the pins for details in a balloon, and click the title in the balloon for a full analysis.

The first pair of maps is intended for journalists and the public. It highlights the longest-waiters, and you can click on the pins for year-on-year comparisons of the total number waiting, 18 week waiters and 52 week waiters. All data is for all specialties combined (see below for specialty-level data).

Long-waiters:  by Trust (Provider basis) and by PCT (Commissioner basis)

The second pair of maps is designed more for NHS managers and clinicians. It looks at the challenge of achieving the new RTT waiting times target, and the pins show the waiting time achieved by 92 per cent of the waiting list (the new target for this measure is 18 weeks). Click on the pins to see estimates of how hard it will be to achieve the new target, both with and without improving patient scheduling. For more details about the methodology see our earlier blog post on the new target. All data is for all specialties combined, and the analysis therefore assumes that resources can be deployed flexibly between specialties.

Achieving the new target: by Trust (Provider basis) and by PCT (Commissioner basis)

To drill down to specialty level, or to jump straight to a particular Trust or PCT, you will find a full set of detailed reports at the Gooroo website.

Full analysis by Trust/PCT and by specialty: All 18 week reports at specialty level

Merry Christmas!

Wow. Just wow. The number of English patients waiting more than a year has halved in October, to 10,911 (down from 20,052 in September). Just one Trust (Sheffield) has more than 1,000 one-year waiters, down from five Trusts in September. All specialties reflect the change, and it’s huge.

Alright, probably most of this was due to validation and data cleaning. But that is still a worthwhile thing to do, because unless very-long-waiting patients are validated there is no way of telling who really needs treatment and who is a data error. This is comfortably the best performance ever recorded by the NHS on one-year RTT waits, and I look forward to further gains as the new waiting-list target beds in.

A full set of stats with time trends can be downloaded in our waiting times fact checker here: Gooroo NHS waiting times fact checker.xls

So what about the new target that 92 per cent of the waiting list (incomplete pathways) should be within 18 weeks? Here’s the trend, and it shows how long 92 per cent of waiting list patients were waiting each month, England-wide.

At the time of the General Election, May 2010, the NHS in England came within a whisker of achieving the new target. Then things deteriorated towards winter and, apart from a summer blip, have been pretty much improving ever since then. We are in a much better position now than we were a year ago.

This overall picture is replicated at specialty level too. The specialty chart is pretty congested (there are 20 specialties on it), but you can see that all specialties are broadly moving as a pack. Even neurosurgery, which was breaking away as a problem area, is coming back down again now.

The Operating Framework insists that the new target is met in every Trust and every specialty, and the next chart shows what proportion of Trust-specialties are achieving it already. (This analysis includes all 2,251 Trust-specialties where at least 100 patients were on the waiting list.)

The above chart replicates the overall picture on over-18-week waiters: record-breaking performance at the time of the General Election, a decline over winter, and then an improvement which is being sustained. But it still shows that one-third of provider specialties are not achieving the target, so much of the NHS has work to do to get through winter and achieve the target next year.

Who has the longest waiters? Here’s the top twenty, ranked by the 92nd centile waiting time (and showing the number of one-year waiters too).

The total number of patients waiting continues to follow the seasonal trend of recent years:

This is interesting in itself. How can the NHS be maintaining its waiting list so precisely? Somehow the system must be responding in minute ways to preserve the status quo. Surely, if we can keep the waiting list static, we could steadily reduce it too? One day, perhaps, we will cease to be satisfied with maintaining a waiting list and just get rid of it. It’s always nice to have a dream.

How hard are we all working? Here’s the activity trend for admitted patients:

Again, an exact mirror of recent years. No sign of an austerity crunch, and no increase in productivity either.

The overall verdict? Steady as she goes, really. The trends suggest that we are heading for a repeat of last year. That means winter waiting list pressures when everybody downs elective tools for Christmas and New Year, followed by a recovery in the Spring.

The Government has listened, understood, and acted. The new RTT waiting times target is aimed directly at cutting the backlog of long-waiters, and elbows aside a target regime which actually punishes hospitals for treating long-waiting patients. The change, long called-for in this blog, is very welcome.

But no target is perfect. Targets always create problems of their own, distorting incentives and encouraging undesirable behaviours. Now that the perversities of the current regime have had their day, can we predict the nasties that the new target is going to throw up?

Happily, we don’t need to pull out our crystal ball. The new target is similar enough to the maximum waiting time targets of the 1990s that we just need to cast our minds back a few years. The two biggest problems then, and in the future, are likely to be distorted clinical priorities and hidden waiting lists.

Distorted clinical priorities

Point a TV camera at any NHS manager, and ask them: which is more important, clinical priorities or waiting time targets? They will rightly answer “clinical priorities”.

Now take the camera away, threaten them with loss of income or employment if they fail to treat their long-waiting patients, and turn a blind eye if clinical priorities are delayed. The consequences are as obvious as they are shameful. But delaying urgent patients to make room for long-waiters has happened before, and it may happen again.

Hidden waiting lists

Then there is the temptation to create “hidden” waiting lists, so that long-waiting patients don’t show up on the incomplete pathway figures.

This can be done blatantly (hiding referrals in drawers, creating “pending lists”, reclassifying patients as “planned”, or offering unreasonable appointments). Sometimes it happens through inattention (post-treatment follow-up backlogs). Sometimes it is the result of deliberate local policy (misusing low-effectiveness criteria to block or delay referrals).

 

So the new target, welcome though it is, leads us to new challenges and new dangers. They cannot be dealt with by national targets and national data collections; they must be tackled locally.

Good planning and management are clearly essential. But so is openness about local practices and policies; if patients and clinicians understand what is being done and why, you can be sure they will protest loudly and often if target-chasing ever dominates over basic fairness and clinical safety.

At dawn on the 17th of November, Andrew Lansley and I appeared together on Radio 5 Live for the Government’s pre-announcement of its new waiting times target. It was a friendly affair rather than a duel, because the new target is very welcome and so we were in the happy position of agreeing with each other.

Why is it so welcome? If you’ve been following this blog for a while, you will know that I am a longstanding critic of the main existing target (that 90 per cent of admitted patients must have waited less than 18 weeks since referral). The reason, quite simply, is that if you have lots of long-waiters then the target restricts your ability to treat them.

The new target is much better because it stops the backlog of long-waiters from building up in the first place. The target, which is confirmed in the new Operating Framework (para. 2.31), is:

that 92 per cent of patients on an incomplete pathway should have been waiting no more than 18 weeks. The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.

The NHS has never actually achieved this level of performance, although it did come very close last year, achieving 91.9 per cent of the waiting list within 18 weeks at the time of the General Election. How hard will it be to achieve?

The statement issued to the media by the Department of Health estimated that “In practice, the new standard will mean the NHS will have to trim about 50,000 from its waiting lists”. I couldn’t quite replicate this figure, but as we’ll see in a moment it is as good an estimate as any. At 2 per cent of the waiting list, or 4 per cent of monthly activity, it doesn’t sound too hard.

There are various ways of looking at the numbers. If we simply take the total size of the waiting list (2,586,583) and the current number waiting over 18 weeks (242,540), then to achieve the target by cutting the backlog we need to reduce the list size by 38,710 (bearing in mind that both the total list and the over-18-week waiters are being reduced at the same time).

That calculation assumes that we can net-off the under-achieving services against the over-achieving ones. In practice, though, the target must be met in every service. If we tackle the target by brute force by treating the backlog, without netting-off pressures between one service and another, we find that a heftier 90,000 extra activity would be needed to bring the existing backlogs down to target level. This still doesn’t look too bad, at only 0.6 per cent of annual (admitted and non-admitted) activity.

But, as usual with NHS pressures, the challenge is not spread evenly around the NHS. It is clustered. Taking all specialties together, here is a map showing the waiting time exceeded by the top 8% of patients on the list (all data is for September 2011 from DH):

We can get a better picture by going right down to specialty level; there are 1,330 services (by Trust, by specialty) that have more than 50 admissions per month. Some 61 per cent of them are already achieving the new target. We estimate that about 22 per cent more could achieve the target safely with good scheduling alone, without needed to reduce the size of the waiting list. That leaves just 17 per cent that would need to reduce the size of the waiting list (in addition to good scheduling).

(You might guess from those proportions that the England-wide target could be met with good scheduling alone, and you would be right. In fact, if every service implemented good scheduling then we estimate the target could be met nationally even if the English waiting list grew by 50,000.)

When analysing the pressures in each service, we really want to know how many working days it will take to clear the backlog. We want to draw attention to those services that have the biggest pressures. Ideally, we also want to know whether we can get part-way there by scheduling patients in a better order.

The next chart has a go at this. The size of each bubble shows the number of over-18-week waiters at each Trust (considering all specialties together, for now). Its position along the horizontal (x-) axis shows how many working days it would take to achieve the new target, if each Trust simply tackled its backlog starting with the longest-waiting patients (and did so at the rate the Trust currently treats both admitted and non-admitted patients). For comparison, the bubble’s position up the vertical (y-) axis shows how many working days it would take to achieve the target, if good scheduling were also put in place (and, because the necessary details are not published for each Trust, we have had to make a few assumptions about what good scheduling might look like).

Most of the Trusts are piled in a heap around where the axes cross; they don’t need to do much, if anything, to achieve the new target. Then we have a few going out along the horizontal axis, who could achieve the target just by scheduling their patients in a better order; no extra activity is required. Then, rising up the chart, come the big blobs with the biggest problems; these are Trusts where good scheduling isn’t going to save them; somehow they need to cut their waiting lists in a fairly serious way. The four biggest ones from the top right are: Kingston, Taunton, Wirral, and St George’s; all currently have 8 per cent of their waiting list over 26 weeks, and will face a challenge to get that down to 18 weeks.

An all-specialties view is all very interesting, but in practice a gynaecologist isn’t going to be much help with the gastro backlog. So here is the same style of chart for each specialty; one blob per Trust, with the specialty name shown in the bottom right corner of each chart:

As we found previously with one-year-waiters, some of the biggest pressures are found in gastroenterology and “other specialties”. Neurosurgery is also an area for concern, because there are large pressures and because not many Trusts provide this highly-specialised service. You may be wondering if your Trust is one of the pressured ones, so the highest clearance times in the charts above (according to backlog clearance time alone) are:

In conclusion, the new target is within reach for the NHS as a whole. Things may slip over the winter but, come the spring, the target should be achievable nationally as Trusts improve their waiting management and recover the winter backlog.

Looking in greater detail, there are many Trusts and specialties (we estimate around 17 per cent) where some backlog clearance will be required. Within that, some have very challenging positions and may need help from their neighbours with their backlog clearance. In all cases good planning, using an advanced planning tool that models waiting time dynamics, will help Trusts and Commissioners to ensure that recurring and non-recurring resources are deployed to achieve the new target sustainably.

This post first appeared at HSJ blogs