NHS gooroo blog

Archive for January, 2012

The latest RTT waiting times stats for England came out last week, so what do they tell us about local waiting times at Trusts and PCTs?

Interactive maps

If you want analysis for a particular Trust or PCT, by specialty, then you can look them up here. Or for an all-specialties view you can drill down through these interactive maps; just click a pin to get year-on-year comparisons of the total waiting list, over-18 week waits, and over-one-year waits. The pin colours show the number of over-one-year waiters.

The toughest backlogs

The maps show where the backlogs are, but how difficult will they be to clear? To answer this, we need a more detailed analysis, and we also have to make some assumptions because not all the data we need is published.

We’re working at all-specialties level, so we are assuming that resources can be allocated in ways that even out the pressures. We’re working with RTT waiting times, so we are assuming that all stages of pathway can be optimally managed. We’ve made estimates around addition rates, urgency rates, removal and cancellation rates, and patient booking tactics. Finally, we’ve assumed that waiting lists are being accurately reported to the Department of Health. That’s quite a lot of assumptions, so the results are illustrative not definitive. Nevertheless they are interesting.

Let’s look at how difficult it will be for Trusts and PCTs to achieve the new, improved target that 92 per cent of the waiting list (incomplete pathways) must be within 18 weeks.

If Trusts and PCTs address their backlogs by treating them in a “waiting list initiative” (aka “chopping the tail off the waiting list”), then they are almost certainly going to be wasting money. Our analysis suggests that 90 per cent of Trusts and PCTs should be able to achieve the new target without reducing the size of their waiting list. Many of the rest have only a trivial backlog to clear: less than two days’ work. Also, many of the Trusts with apparent pressures have suspected or known data reporting problems linked to the installation of new IT systems, which means that much of the apparent backlog will eventually evaporate through waiting list validation.

With all those caveats, then, here are the PCTs with the biggest backlog-clearance challenges ahead of them. The numbers show the number of working days’ activity needed to clear the backlog, even after good waiting list management has been put in place:

• Wirral PCT: 33 days
• Somerset PCT: 18 days
• Bath and North East Somerset PCT: 10 days
• Blackpool PCT: 6 days
• Oxfordshire PCT: 6 days
• Croydon PCT: 4 days
• Warwickshire PCT: 4 days
• Great Yarmouth and Waveney PCT: 2 days

The list of highly-pressured Trusts, unsurprisingly, shows some overlap:

• Wirral University Teaching Hospital NHS Foundation Trust: 39 days
• Taunton and Somerset NHS Foundation Trust: 24 days
• Mid Staffordshire NHS Foundation Trust: 22 days
• South Warwickshire NHS Foundation Trust: 21 days
• Royal United Hospital Bath NHS Trust: 20 days
• The Robert Jones And Agnes Hunt Orthopaedic Hospital NHS Foundation Trust: 13 days
• Weston Area Health NHS Trust: 11 days
• Winchester and Eastleigh Healthcare NHS Trust: 9 days
• Oxford Radcliffe Hospitals NHS Trust: 8 days
• Yeovil District Hospital NHS Foundation Trust: 8 days
• Blackpool Teaching Hospitals NHS Foundation Trust: 7 days
• Imperial College Healthcare NHS Trust: 5 days
• Queen Victoria Hospital NHS Foundation Trust: 4 days
• Croydon Health Services NHS Trust: 3 days
• Bradford Teaching Hospitals NHS Foundation Trust: 2 days
• Tameside Hospital NHS Foundation Trust: 2 days
• James Paget University Hospitals NHS Foundation Trust: 2 days

Where time stands still

I’d like to pick out one of these Trusts because there is something strange about its waiting list. The wonderfully-named “The Robert Jones And Agnes Hunt Orthopaedic Hospital NHS Foundation Trust” (usually shortened to the RJAH) is a lovely specialist Orthopaedic hospital in the Welsh borders, set in beautiful hilly countryside. Their waiting list has a hill in it too, quite a big one, and it looks like this (see the dotted red line; data from the Department of Health):

That’s quite a peak. Luckily for the Trust, it lay just below 18 weeks in November, so they just managed to achieve their admitted patient target (90% within 17.8 weeks) and non-admitted patient target (95% within 18.0 weeks) during November. But how are they going to cope in December, when the peak has moved on and will be hitting 22 weeks?

Except that this peak isn’t going to move on. Curiously, it always stands still. Here is is the previous month’s peak, in October:

Like the Welsh hills around the hospital, this peak stays where it is. It has remained in exactly the same place ever since it first appeared from nowhere in October 2009. Actually, not quite from nowhere, because one can hardly help noticing that the Trust’s over-one-year waiters disappeared at exactly the same time. Here is the moment the peak appeared:

How are we to explain this phenomenon?

It can’t be clock pauses, because incomplete pathways data is not supposed to be adjusted for pauses. I wrote to the Trust a month ago to offer them an opportunity to provide an explanation, but they have not responded. So as things stand, I am struggling to think of an innocent explanation, and if anybody can come up with one then I’d like to hear it.

English waiting times improved in November, and were in good shape for the run-up to winter. The total waiting list was down, and admissions were up, with both closely following last year’s seasonal trend.

Long-waits were down too. The number of over-one-year waiters, which fell sharply in October following major validation exercises, was 10,407 (of which 3,161 were at Mid Staffs). The NHS edged closer to success against the new target, with 92 per cent of the waiting list within 18.9 weeks (or, looking at it the other way, 91.1 per cent of the list within 18 weeks).

The original data analysed in this post is published by the Department of Health here. You can download our waiting times fact checker here:

Gooroo NHS waiting times fact checker

November 2011 had the same number of working days (22) as November 2010, and the number of admitted patients treated is almost identical.

The total number of patients on the waiting list is also tracking last year’s numbers very closely.

Looking at the long-waiters, 92 per cent of the waiting list is within 18.9 weeks, almost exactly the same as October (19.0 weeks) but much better than the previous year (20.1 weeks in November 2010).

At specialty level Neurosurgery continues to recover, and the major surgical specialties reflect the overall trend.

Is there no bad news at all?

Well, perhaps, but only slightly. The proportion of services (by Trust, by specialty) achieving the new “92 per cent of the waiting list within 18 weeks” target has fallen slightly, though no worse than it was a year previously.

We will publish full details by Trust, PCT and specialty as soon as we finish processing the data, but in the meantime here are the top twenty highly-pressured Trusts in England. Congratulations to Sheffield Teaching, who last month were at number 6 and had the distinction of being the only Trust in England with over 1,000 one-year waiters; they have now dropped off the table entirely with only 65 one-year waiters.

Trust	92% of waiting list is within	Position in November	Change	Position in October	Over-one-year waiters on list
Mid Staffordshire NHS Foundation Trust	52+ weeks	# 1	no data	no data	3161
Wirral University Teaching Hospital NHS Foundation Trust	40.8 weeks	# 2	no change	from # 2	706
Staffordshire and Stoke on Trent Partnership NHS Trust	36.5 weeks	# 3	no change	from # 3	146
Buckinghamshire Healthcare NHS Trust	28.2 weeks	# 4	up 6	from # 10	0
Guy’s and St Thomas’ NHS Foundation Trust	28.0 weeks	# 5	no change	from # 5	659
Great Ormond Street Hospital for Children NHS Trust	27.5 weeks	# 6	up 15	from # 21	32
Surrey and Sussex Healthcare NHS Trust	27.4 weeks	# 7	no change	from # 7	114
Taunton and Somerset NHS Foundation Trust	27.0 weeks	# 8	up 1	from # 9	0
Royal Devon and Exeter NHS Foundation Trust	26.9 weeks	# 9	up 4	from # 13	0
United Lincolnshire Hospitals NHS Trust	25.7 weeks	# 10	down 6	from # 4	140
Royal United Hospital Bath NHS Trust	24.9 weeks	# 11	up 3	from # 14	37
Bolton NHS Foundation Trust	24.4 weeks	# 12	no data	no data	267
South Warwickshire NHS Foundation Trust	24.4 weeks	# 13	down 1	from # 12	7
Yeovil District Hospital NHS Foundation Trust	24.2 weeks	# 14	up 4	from # 18	1
South London Healthcare NHS Trust	23.6 weeks	# 15	down 7	from # 8	300
Pennine Acute Hospitals NHS Trust	23.6 weeks	# 16	up 6	from # 22	118
Warrington and Halton Hospitals NHS Foundation Trust	23.4 weeks	# 17	up 6	from # 23	41
Derby Hospitals NHS Foundation Trust	23.0 weeks	# 18	up 1	from # 19	0
South Tyneside NHS Foundation Trust	22.9 weeks	# 19	up 1	from # 20	0
Kingston Hospital NHS Trust	22.6 weeks	# 20	down 3	from # 17	158

Treat your long-waiting patients!

Don’t treat your long-waiting patients!

You can forgive the NHS for being confused. A Trust with a long-wait backlog gets clobbered whatever it does: with fines under the NHS Contract if it treats its long-waiters, and via performance management if it doesn’t.

There is a way through the conundrum, but it’s messy. (At least the NHS can console itself with the thought that it didn’t make the mess in the first place.)

The key point is that, from April 2013, the target regime is expected to focus on the waiting list (when 92% of incomplete pathways must be below 18 weeks). So if you work at a Trust with lots of long-waiters then, whatever you do this year, you need to tackle that 18-week backlog.

Unfortunately, when you treat those long-waiters you will probably breach the admitted and non-admitted targets which live on, zombie-like, in the NHS Contract. If your PCT Cluster is sensible about it, they will voluntarily refrain from enforcing these zombie targets. (And, even if they don’t, being “performance managed” is perhaps more likely to keep you awake at night than the prospect of a fine.)

So in operational terms, if you have an 18-week backlog, the right thing to do is to treat your long-waiting patients, preferably with blessings from your PCT Cluster. This is more than just good tactics; it is consistent with the four principles of good waiting list management:

• Treat more urgent patients more quickly
• Treat patients with similar priority broadly in turn
• Keep the longest waits to a reasonable level
• In doing all this, don’t waste the available capacity

So that’s the operational approach. What about planning?

Here things get a little trickier, because you have two completely different kinds of target to juggle: the zombie targets based on patients as they are being treated, and the new ones based on patients who are still waiting. Happily it turns out that this conflict is easy to resolve.

In a well-managed waiting list (following the four principles above), it turns out to be easier to achieve the incomplete pathways target than the zombie targets. So the solution is simply to plan your activity and capacity to achieve the more difficult (i.e. the zombie) targets. In practical terms this means that, when you are running your planning model, you should set the waiting times targets to sustainably achieve 90% of admissions and 95% of non-admissions within 18 weeks; you do not need to model the 92% incomplete pathways target because it will automatically follow.

If all goes well then this muddle of targets should only last for a year. Then we can all focus on what is really important: stopping long-wait backlogs from building up in the first place.

In the meantime it is within the gift of PCT Clusters to resolve the confusion locally by choosing not to enforce the zombie targets in the NHS Contract, and so clear the way for performance management to bear down on the backlogs.