NHS gooroo blog

Archive for April, 2012

So, is NHS performance on waiting times, “strong” or an “embarrassment”
(@HSJEditor via Twitter)

How did the HSJ (“NHS reports strong performance on 18 weeks targets”) and the Guardian (“Number of NHS patients waiting over 18 weeks for treatment up 27%”) manage to draw opposite conclusions from the same waiting times statistics?

The Guardian explained its numbers thus:

A total of 26,417 people in England waited more than 18 weeks to be treated in February this year compared to 20,662 in May 2010, when the government was formed – a 27% rise.

Looking at the data (spreadsheet here), we can see where those figures came from. 26,417 is the number of patients admitted as inpatients and daycases, during February 2012, who had waited over 18 weeks (adjusted for clock pauses) before being treated. 20,662 is the corresponding figure for May 2010, the month of the General Election.

That’s a 27.9 per cent increase. But an increase in what? Not in the “number of NHS patients waiting”: if you look at the waiting list figures (the so-called “incomplete pathways”), you find that the number of over-18-week waiters still on the waiting list fell by 16 per cent over the same period, from 209,411 to 175,549 (which, as it happens, is an all-time low).

No, the increase was in the number of over-18-week waiters being treated, and at this point we need to remind ourselves that treating long-waiting patients is a good thing (and certainly much better than leaving them on the waiting list). The NHS in England has recently been treating a lot more long-waiters in an effort to clear the over-18-week backlog: in the year to February 2012 some 337,264 over-18-week waiters were admitted (9.3 per cent of all admissions), compared with only 283,128 (7.8 per cent of admissions) in the previous 12 months.

So the Guardian headline needs a bit of adjusting. Using the same figures it could have said “Number of NHS patients treated after waiting over 18 weeks up 27%”. Or, to put the focus on “NHS patients waiting”, it might have read “Number of NHS patients waiting over 18 weeks for treatment down 16% to record low”. Either way, it’s hardly “a huge embarrassment”.

A similar confusion over the figures popped up elsewhere this week, with the CQC’s large-scale survey of inpatients reporting that waiting times had gone up. Again, the figures show that the number of long-waiters picked up in the inpatients survey had increased, which again is a measure of long-waiters being treated not of long-waiters still waiting.

What is surprising about the inpatient survey is the very high proportion (14 per cent) reporting that they had waited longer than six months, when according to the national RTT statistics the figure for the same period (October 2011 to January 2012) was only 3 per cent. Perhaps the answer lies in the wording of the question: according to the summary report “the survey asked respondents how long they had to wait to be admitted to hospital, from the time they first talked to a health professional about being referred for a hospital admission”. This isn’t quite the same as the waiting time from referral to treatment, which may (or may not) explain the difference.

So what’s the verdict: “strong”, or an “embarrassment”? Looking at the waiting list, in February 2012 the numbers of patients waiting longer than 18, 26, 39 and 52 weeks were the lowest ever recorded. So were the 90th, 92nd and 95th centile waiting times. So (not that it means very much) were the mean and median waiting times. A “strong” performance? I hope we can all agree that it is.

Here is the local picture on 18 week waits, fully updated with the February 2012 waiting times data just released by the Department of Health for England.

If you want to pick a Trust or PCT, and get a full analysis of the pressures in any specialty, then all the detail is here: Gooroo reports

Where are the long-waiters?

If you’re a local journalist, or just want to see where the longest-waiting patients are, here is a summary map. Click on any pin to get year-on-year data for the total list size, 18-week waiters, and over-one-year waiters.

If you want the same map broken down by specialty, here it is. In this map the pins are clustered, so you can click to zoom in on any Trust. When the Trust turns into a pin, click it, and you’ll get the detail in a balloon for one specialty. To see more specialties, look for the page number in the bottom right corner of the balloon.

For a population-level view of where the longest-waiters are, here is a summary map on a commissioner (PCT) basis:

Similarly, here is the PCT map broken down by specialty.

How hard is the 92 per cent target?

If you work in the NHS, and want to know how difficult it will be to achieve the new target (that 92 per cent of incomplete pathways must be within 18 weeks), then these interactive maps have the detail.

First by Trust:

and by PCT:

Again, in this map the pins are clustered: click to zoom in; when the pie chart turns into a pin, click it, and you’ll get the detail in a balloon for one specialty. To see more specialties, scroll through the page numbers in the bottom right corner of the balloon.

The NHS in England met all its 18-week waiting times targets again in February, consolidating January’s first-ever success on all three measures. Although long-waits are improving in the run-up to April’s new target, the overall number on the waiting list remains unchanged compared with recent years.

The number of over-one-year waiters on the waiting list fell again to a new record low, but progress is slowing as the blitz on validating long-waiters runs out of steam. Sure, 5,696 over-one-year waiters is a lot better than 14,880 the year before, but it’s still 5,696 too many. When the NHS admits 50 times as many patients every month, why are these patients still on the waiting list? Also, why are so many (2,132) in London?

For all the stats and time trends, you can download our updated waiting times fact checker here.

Imperial are still on a reporting holiday, but we welcome the Robert Jones and Agnes Hunt orthopaedic hospital back to the data series (minus the suspicious hill in the middle of their waiting list); it is much better to have those one-year-waiters where everybody can see them, than to risk them dropping out of sight and out of mind.

Apart from that there are the usual caveats: the data excludes patients who are being held up by referral restrictions, and backlogs that may be building up for post-treatment follow-up.

England-wide picture

Both admissions and the total list size continue to track the trajectories of recent years. No sign of austerity hitting overall activity, nor of the NHS reducing waiting lists below their current level.

The new target, that 92 per cent of the waiting list (incomplete pathways) must be below 18 weeks RTT, starts  in April. At national level the NHS achieved it ahead of time in January, and has continued this improvement in February.

All major specialties reported improvement against this measure, except Orthopaedics which roughly maintained its position.

The new target must be met in every specialty and in every NHS organisation and, although more services are getting there, some 28 per cent of Trust-specialties are still below target. Expect this number to improve sharply over the next two months as Trusts scramble to avoid the “performance management” thumbscrews.

 

Trust top twenty

The twenty Trusts with the greatest waiting time pressures (omitting Imperial who did not submit data) are:

Trust	92% of waiting list is within	Position in February	Change	Position in January	Over-one-year waiters on list
The Robert Jones And Agnes Hunt Orthopaedic Hospital NHS Foundation Trust	35.4 weeks	# 1	no data	no data	63
Royal Devon and Exeter NHS Foundation Trust	27.7 weeks	# 2	no change	from # 2	0
Guy’s and St Thomas’ NHS Foundation Trust	25.7 weeks	# 3	no change	from # 3	457
Pennine Acute Hospitals NHS Trust	25.0 weeks	# 4	up 5	from # 9	138
Croydon Health Services NHS Trust	24.2 weeks	# 5	up 2	from # 7	93
Surrey and Sussex Healthcare NHS Trust	24.0 weeks	# 6	no change	from # 6	86
St George’s Healthcare NHS Trust	23.9 weeks	# 7	up 32	from # 39	419
Bolton NHS Foundation Trust	23.7 weeks	# 8	up 2	from # 10	102
Royal United Hospital Bath NHS Trust	23.0 weeks	# 9	up 11	from # 20	5
King’s College Hospital NHS Foundation Trust	22.8 weeks	# 10	up 7	from # 17	242
Royal National Orthopaedic Hospital NHS Trust	22.7 weeks	# 11	up 8	from # 19	1
Mid Staffordshire NHS Foundation Trust	22.1 weeks	# 12	down 11	from # 1	7
Bradford Teaching Hospitals NHS Foundation Trust	21.9 weeks	# 13	up 2	from # 15	0
Royal Berkshire NHS Foundation Trust	21.9 weeks	# 14	down 2	from # 12	0
North Bristol NHS Trust	21.9 weeks	# 15	up 10	from # 25	125
Warrington and Halton Hospitals NHS Foundation Trust	21.6 weeks	# 16	down 5	from # 11	40
Barts and The London NHS Trust	21.5 weeks	# 17	up 5	from # 22	51
Taunton and Somerset NHS Foundation Trust	21.4 weeks	# 18	down 10	from # 8	8
Hampshire Hospitals NHS Foundation Trust	21.3 weeks	# 19	up 5	from # 24	37
University College London Hospitals NHS Foundation Trust	21.3 weeks	# 20	up 8	from # 28	263

 

Congratulations are in order to the following Trusts for dropping out of the table altogether with big reductions in long-waits: Weston (whose 92nd centile fell from 24.9 to 16.9 weeks); Great Ormond Street (25.5 to 20.1), and Staffordshire and Stoke on Trent Partnership (with a whopping 23.4 to 12.1 week reduction).

The next 18-weeks statistics release from the Department of Health is expected at 9:30am on Thursday 17 May.

Usually when Celtic nations borrow ideas from the English, they pick the best bits and leave the not-so-good stuff behind. Not this time. Scotland has just “achieved” its first 18-weeks referral-to-treatment (RTT) target, but this success is an illusion. Behind a distorting target, long-waits are shooting up at an astonishing rate.

As if that isn’t bad enough, the NHS in Scotland is also enduring a torrent of headlines about the Lothian waiting times scandal, with lurid tales of inappropriate offers, staff suspensions, fiddles, and bullying. Anyone outside Scotland, wanting to see from a safe distance just how nasty a waiting list scandal can get, should take a look (before checking out the antidote here).

How did it go so wrong?

Fundamentally, Scotland picked the wrong target. It copied the headline English target (that 90 per cent of completed patient journeys must be within 18 weeks RTT, adjusted for periods of patient unavailability). As in England, any Health Board can achieve the target simply by refusing to treat patients who have already passed the 18-week mark. And that, it seems, is exactly what has happened.

The Scottish Government wanted the 90 per cent target met by December 2011, and right on cue the NHS achieved 92 per cent. But they achieved it by suppressing the number of long-waiters being treated to a record low (figures from Table 1 here):

This would be fine, if it were genuinely the result of having fewer long-waiters still on the waiting list. But the opposite is true. We cannot make a direct comparison on a RTT basis because (unlike England) Scotland does not publish RTT figures about the waiting list itself. But there is data available for the separate outpatient and inpatient/daycase stages of the patient journey, and the official charts (reproduced below) could hardly show more starkly how the number of long-waiting patients still on the list is going up like a rocket.

It doesn’t look any prettier in raw numbers. Year on year, the number of patients still on the waiting list over 12 weeks went up from 1,769 to 6,141 for new outpatients, and from 210 to 2,019 for inpatients and daycases. The big numbers are concentrated in Lothian (as patients wrongly declared “unavailable” are returned to the waiting list), but there are sharp increases in other Health Boards too, showing that this is not a Lothian-specific phenomenon.

It is such a pity. These outpatient and inpatient/daycase targets, which apply to patients who are still on the waiting list, were meant to be the magic bullet that would stop backlogs building up, and stop the Scottish referral-to-treatment target from distorting waiting times as they did in England. But the backstop has failed. The distorting target won, it prevents Health Boards from treating enough long-waiters, and so the number of long-waiters still on the waiting list is going up.

Are there any plans to sort this out? The Scottish Government will take half a step in the right direction, with a 12 week legal guarantee covering some inpatients and daycases due to start in the autumn. But putting a small patch on a weakened backstop will not fix the underlying problem.

Instead, Scotland should look across the border and learn again from England’s mistakes. The new English target is the one to copy: that 92 per cent of patients still waiting must be below 18 weeks, on a referral-to-treatment basis and without adjustment for patient unavailability.

Even better, Scotland could do it first. Although English Health Ministers have accepted the logic of a waiting list based target, and gone to all the trouble of creating one, they have bizarrely delayed its full implementation until at least April 2013. Scottish Ministers could switch targets now, and rapidly achieve and sustain the genuine short-waits that they wanted in the first place.