In a parallel post I explain why PTLs should now change, and evolve into “active PTLs” which work continuously to minimise waiting times for all patients. This blog post explains how in a bit more detail, describing the rules for operating active PTLs.
I’ll also take the opportunity to sketch out briefly the origins of PTLs, because they were a tremendous achievement in their day. It is easy to forget just how unmanaged the NHS’s waiting lists were in the 1980s, and the originators of PTLs deserve credit for their roles in making today’s shorter NHS waiting times possible.
Let’s start with the active PTL rules.
There are only five rules, and they aren’t particularly complicated. The difficult part was excluding all the alternatives, and quantifying the behaviour of the system to allow the calculation of booking rules and waiting times; this took two years of PhD-level research, and the study of over a billion simulated patient bookings. If you want to find out more about the simulator research, you can download the research papers here, and you can try the simulator by logging in here and clicking SimView (registration and use is free to NHS).
The purpose of laying out the rules in this blog post is to stimulate interest in the next stage, which is to take the active PTL rules beyond the simulator and into the real world. If you are interested in joining those hospitals who have already expressed an interest then you can email me at email@example.com
Before implementing an active PTL, you will first need to:
a) know, at subspecialty and stage-of-pathway level, the size of waiting list that is consistent with your waiting times targets;
b) ensure that enough slots will be delivered through your available capacity to achieve and sustain a waiting list that is no bigger than that; and
c) carve out the right number of slots for urgent and cancelled patients.
A free booking rules calculator that helps with all this is available after login at nhsgooroo.co.uk.
The active PTL rules
The rules work differently for fully-booked and partially-booked services. In a fully-booked service, which should include all services using direct Choose & Book, all patients are invited to make an appointment. In a partially-booked service, which only works when the provider has control over all appointments, slots are only available a limited number of weeks ahead (typically 6 or 4 weeks) to minimise disruption caused by staff taking leave. The rules work for both clinics and theatres.
The active PTL rules are driven by five different events:
1) An urgent patient needs booking
Find out how long the patient can safely wait because of their clinical condition. Book them into the latest empty urgent or routine slot within that time. If no empty slots are available, create one by cancelling the routine patient who will be least inconvenienced.
2) In a fully-booked service: a routine patient has had their appointment cancelled and needs rebooking
Offer the patient a choice of any empty urgent or routine slot in the first three weeks in which empty slots are available.
3) In a fully-booked service: a new routine patient is added to the waiting list
Offer the patient a choice of any empty routine slot in the first three weeks in which empty routine slots are available.
4) In a partially-booked service: empty routine slots become available
Select routine patients for booking in the following order: cancelled patients first (starting with the longest-waiters), then new patients (again starting with the longest-waiters). Book each patient into the soonest empty routine slot, until all available routine slots are filled.
5) There is an empty urgent or routine slot at very short notice which is at risk of being wasted
Fill the slot, ideally with an urgent patient or by bringing forward a long-waiting patient, or alternatively with a new routine patient.
Tactics that are not in the rules
Avoid holding extra slots in reserve. Avoid running services that neither offer bookings to all patients (if fully-booked), nor fill all available routine slots (if partially-booked). Avoid “rippling”.
A short history of PTLs
According to Anthony McKeever (who was there at the time), PTLs all came about in the mid to late 1980s.
The thought leader was Professor John Yates who studied in great detail the influences that led to long waiting times. By analysing the available data he identified that if you increased the focus on the back of the queue then long waits could be greatly reduced.
Mersey RHA, under Sir Duncan Nichol and Sir Donald Wilson, turned this into a policy to achieve 2 year maximum inpatient waits, which sounds long today but was ground-breaking at the time.
This policy was developed into practical methods by Kevin Cottrell and Anthony McKeever. First they developed the concept of Personal Treatment Plans, which were individualised for each long-waiting patient and agreed with their consultant. These developed into provider-led Patient Treatment Lists, and these were the first PTLs. As other NHS organisations picked up the techniques, the PTL abbreviation stuck but came to stand for a variety of different words.
First published at HSJ blogs