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The whole point of developing a plan for the coming financial year is to resolve, at the outset, the tensions that are pulling your organisation in opposite directions.

So on the one hand you have demand to keep up with, and 18-week waiting times to sustain. On the other hand you have limited money, capacity and staff to do it with. Somehow your plan needs to reconcile those opposing forces.

What if it doesn’t?

Then the problem is effectively handed on for operational managers to resolve. They end up in meetings where the first half is about laying on costly extra capacity to clear the backlog that’s building up, and the second half is about how they need to slow down activity because they’re “over-performing” and the money’s running out.

That agenda, of course, doesn’t solve anything, so the problems fester. In the autumn, following a series of difficult meetings about demand management, some extra money is somehow identified to patch over some of the gaps. But everyone knows that nothing fundamental has really changed.

If life without a proper plan is so unappealing, why do so many NHS organisations begin the financial year without one?

Let’s try this scenario for size: The planning process begins in good time, but it quickly gets complicated. A lot of people need to be involved: general managers, finance, contracting, information, and that’s just from the hospital side. Different people approach the task in different ways, so there is a mix of methods and not all of them are valid. New assumptions are constantly thrown in to try and close the gap, and the model gets ever more complex. A planning analyst gamely tries to hold it all together in a spreadsheet, but it’s massive and people tire of looking at subsequent versions of it. The detail becomes unwieldy and time is running out. Something high-level has to be hammered out at the last minute, just to make the money balance. The detail is then retrofitted pro-rata and the “plan” signed-off.

In short, inclusive bottom-up planning is overwhelmed by complexity, and a top-down settlement has to be imposed instead. If complexity is the enemy, how could the process be simplified and streamlined, so that the bottom-up process can succeed?

Here is how Gooroo Planner solves the problem:

Firstly, we recognise that much of the data going in is a matter of simple historical record (recent activity levels, for instance). These facts can be agreed early on, and there is no need to discuss them further.

Secondly, we’ve taken all those complex calculations and developed them into a single model, based on principles that are widely-accepted across the NHS, fair to all sides, and transparent. So precious negotiating time is not taken up with detailed discussions about method. The calculations cover the whole of the planning period, and also break the plan down week by week so you can meet your objectives continuously through the seasons, and keep your plan up-to-date with events.

Thirdly, all the performance, demand and activity assumptions are laid out clearly and openly for discussion. Ultimately the key to reaching a settlement lies in successfully negotiating these assumptions, so that resources can be released from some areas to relieve pressures in others. So we’ve made it easy to test different scenarios, either item-by-item or by throwing in whole tables of alternatives.

Finally, we provide collaboration tools to get away from those giant emailed spreadsheets. Managed online collaboration means that participants can all see (and where necessary work on) the same plan, in real time, with full audit trails of any changes.

If you’d like to work that way, either to revise your plans for this year or start getting ready for next winter, then get in touch and we will be happy to visit and show you more. Just email info@nhsgooroo.co.uk for a free on-site demo.

The number of patients on the English waiting list increased sharply in March, according to the latest figures, and the total list size is now larger than in recent years.

There had been speculation that winter bed pressures, which caused cancellations of elective surgery in March and April, would lead to longer waiting lists. But the number of patients admitted from the waiting list was broadly on track in March, so the picture is not quite so neat and rising referral rates are part of the explanation.

The number of patients waiting is an early indicator of waiting times pressures to come, so a rising waiting list is cause for concern. But it takes time for the pressures to feed through. The position on 18 weeks was broadly stable in March with only a small deterioration, and the number of one-year-waiters broke new records as providers clear their extreme long-waiters before the zero-tolerance penalties begin in April. One-year-waiters fell to just 473 at the end of March, down from 665 the previous month and 5,149 the previous year.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

England-wide picture

The officially-reported number of patients waiting (i.e. incomplete pathways) rose sharply, and looks very high. But in recent years the NHS has been improving the coverage of its reporting, so…

If you strip out the effects of step-changes in the data then the list size looks more in line with the last few years. Nevertheless the increase in March has taken it to a new seasonal high which is cause for concern. (The adjustments used in the chart below take into account the return of North Bristol to this data series, which accounted for 27,185 of the increase.)

Admission rates continue to follow the broad pattern of previous years, despite the widely-reported winter pressures. Admissions per working day did fall slightly compared with February, when in previous years they have risen into March, but these figures do not show widespread cancellations on anything like the scale of the very cold winter of 2010.

One-year-waiters have again fallen rapidly, in advance of the zero-tolerance penalties for one-year-waiters which began in April. Other long-wait measures remain broadly steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, remains steady with just a small deterioration.

At specialty level, General Surgery finally tipped across the line to fail narrowly against the target. Orthopaedics continued to deteriorate, as did the more specialised long-wait specialties.

The proportion of services at provider-specialty level remained stable, with just a small decline from 85.2 to 85.1 per cent achieving the incomplete pathways target.

 

Provider top ten

Congratulations to the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) for nearly halving their one-year-waits backlog. They had to admit some 53 one-year-waiters to do this, which was the equal highest number of over-one-year admissions in England.

Trusts with the largest numbers of one-year-waiters remaining are: 79 at East Kent, 57 at King’s, 54 at RJAH, 42 at the Royal Orthopaedic, 39 at Barts, 16 at Doncaster, 16 at Royal Devon, and 13 at Southampton.

As mentioned above, North Bristol have finally restarted submitting waiting list data for the first time since July 2012. Bradford are still absent from this data series.

The April 2013 data is due out at 9:30am on Thursday 20th June 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick an NHS Trust or independent sector provider, or an NHS Commissioner, you can get a full analysis of the pressures in any specialty here.

Where are the very-long waiters?

The following maps compare one-year waits, 18-week waits, and total waits, with the values a year before. The first map shows providers, and the second shows commissioners and is therefore on a population basis.

The provider map shows NHS Trusts only to avoid map clashes with independent sector providers on the same site, but you can download the full data for all providers and specialties at the end of this post. In the map, click a pin to see the detail, then click the organisation  name to get a full analysis.

 

92 per cent of the waiting list within 18 weeks

The most meaningful (and, from April, the main contractual) waiting time measure is that 92 per cent of the waiting list (‘incomplete pathways’) must be within 18 weeks. So these maps shows how long 92 per cent of the waiting list has actually waited.

You can download a table of all the specialty-level detail here: Map-data.xls

I have a puzzle for you: thousands of patients are apparently missing from the English waiting list. I don’t know where they are (though I’ll have a go at guessing), and I’m hoping some of you can help me.

Here’s the problem.

In principle, we should be able to start with, say, the 4-5 week waiters from the end-of-January waiting list, take away those patients who were admitted and non-admitted from the cohort during February, and (because February was exactly 4 weeks long) end up with an estimate of the 8-9 week waiters on the end-of-February waiting list.

That method would miss any patients who were removed without being seen or treated (for instance ‘validated’ patients who had been reported on the January waiting list in error), but that error should all be in one direction: to make the reported February figure smaller than our estimate. Patients cannot appear on the waiting list with several weeks on the clock out of thin air, can they? So our estimate, minus the reported end-of-February list, should always produce an anomaly that is positive and which reflects validation during February.

Sounds great. But if you actually do the sums you come across some oddities. Several, in fact, as you can see from the supposedly-impossible negative values in the chart below.

1) Missing very-short waiters

The first oddity is for the very shortest waiters. If you take the number of patients across England who have waited 1-2 weeks at the end of January, and knock off February’s admitted and non-admitted patients, then the expected number of 5-6 week waiters at the end of February should be no more than about 177,720. But in fact some 179,087 were reported in the end-of-February waiting list data: more than a thousand too many. That’s the small negative anomaly at 5-6 weeks in the chart above. A thousand-odd patients have appeared in the February figures out of thin air. Where did they come from?

They weren’t new referrals being treated immediately (they could only affect February’s 4-5 week cohort, which should really be part of this oddity as well). So they must only have appeared on the waiting list a week after referral. This, as far as I am aware, is quite common, because paper referrals are often graded for urgency by the consultant before being recorded on PAS, and this process can take as long as a week or two. So if that’s the explanation then that would explain the first oddity.

2) Missing 9-week waiters

The second oddity crops up at 8-10 weeks, and this is larger and more mysterious. At the end of January there were 233,003 patients on the waiting list who had waited 4-6 weeks since referral. After deducting the relevant admitted and non-admitted patients, you are left with an upper limit for 8-10 week waiters at the end of February of about 129,045. But in fact the reported figures show there were 144,434: some 15,389 too many, and causing the large negative anomaly in the chart. That’s a lot of patients suddenly appearing in the February figures. Where did they come from?

I don’t know the answer to this one, which is why I’m asking. But my guess is that this has something to do with cancer pathways. Could it be that some cancer patients are not being reported in the incomplete pathways statistics, but are being reported in the admitted and non-admitted figures? The NHS Standard Contract specifies that cancer patients should be treated within 62 days of referral, which is 9 weeks and coincides nearly enough with this anomaly. If large numbers of cancer patients are not being recorded in hospitals’ mainstream computer systems, which this explanation implies, then that in itself could be worrying because parallel and duplicate administrative systems can lead to patients getting lost.

3) Missing 17-week waiters

The third oddity is around 18 week waits. It isn’t large enough to appear as a negative anomaly in the national statistics charted above (though it does show as a step-change), but if you drill down to Trust level it does produce a negative anomaly for some individual Trusts. Because the cohort-tracking sums are inexact, and because quite a few Trusts crop up in this analysis, I am not going to name Trusts individually but instead will look at the overall pattern.

At some Trusts, the reported number of patients waiting 17-18 weeks at the end of February is higher than you would expect (a negative anomaly at Trust level), and they have no negative anomaly for 18-19 week waiters. In most cases the negative anomaly is small (or a small percentage). But in a handful of Trusts it does look significant; in other words significantly more patients are being reported just within the 18-week target than you would expect.

Again I don’t know what the explanation is, but my guess is that some Trusts (or some parts of some Trusts) might be applying clock pauses to their waiting list figures. That is strictly forbidden; the guidance says (emphasis in original):

“Clock pauses may be applied to incomplete/open pathways locally – to aid good waiting list management and to ensure patients are treated in order of clinical priority – however, adjustments must not be applied to either non-admitted or incomplete pathways RTT data reported in monthly RTT returns to the Department of Health.“

4) Disappearing 18-week breaches

The final oddity is just above the 18-week mark, and this anomaly goes in the opposite direction. From 18-22 weeks, the end-of-February waiting list is around half the expected size, so the anomaly is much more positive than expected.

My guess is that this is the result of waiting list validation being targeted at over-18-week waiters so that they don’t score against the admitted and non-admitted standards. This is a largely redundant tactic now that the main focus of the penalties, from April, is on incomplete pathways; Trusts today would be better advised to focus their validation efforts on patients approaching 18 weeks, rather than those who have already breached.

So there are four oddities in the data. If you can help explain any of them, or at least explain what is happening where you work, then do leave a comment below this post on the HSJ website (either anonymously or otherwise), or contact me in confidence by email or publicly on Twitter.

If you want to dive into the figures, you can download a spreadsheet that contains all the detailed calculations here.

POSTSCRIPT

A few more suggestions that have been put to me since I posted this:

Some missing waiters around the nine-week mark could be Choose & Book patients, who were told by C&B that no appointments were available and therefore raised an ASI (Appointment Slot Issue). Those patients might then be managed on paper by the hospital until their slot is arranged, which might take several weeks, during which they might not be reported as incomplete pathways. (Incidentally, this is a wasteful and risky administrative process, and the patient usually ends up in a similarly-dated slot to the one they would have had if C&B polling ranges had simply been extended.)

Some missing patients close to the 18-week mark at Trust level (though not at national level) are tertiary referrals. These arrive at the tertiary centre with time already on the clock (although there is now the option for the referring provider to take the ‘hit’ on any breaches caused by delays at their end: http://transparency.dh.gov.uk/files/2012/06/RTT-Reporting-patients-who-transfer-between-NHS-Trusts.pdf).

Here is a comment left at the HSJ website:

Anonymous | 2-May-2013 11:13 am

A few points come to mind in response to this article:
- As a general comment, early this (calendar) year, the impending financial penalties for >52 week waiters resulted in a flurry of activity to clear up waiting lists and address data quality issues. This almost certainly has created lots of apparent anomalies that are in fact data quality corrections.
- The >52 week penalties are contained in the standard NHS contract template – you will find that some CCGs have chosen not to include them in the final versions used for their providers. I think this may happen in situations where the provider is on a block contract. This is probably not a major factor though.
- My experience suggests that providers will not stop validating 18 week breaches against the clock stop targets – I am not sure any board or exec would simply not be worried about breaches that aren’t really breaches, financial penalty or not. It is still a core operational standard (as defined by the NTDA) so will still create a fuss if not achieved.
- as regards the missing very short waiters, grading for urgency by clinicans has definitley been known to take longer than 2 weeks. A less than one percent discrepancy could easily be explained by late grading and, probably more commonly, hospitals without single points of referral receipt not getting things on the system ina timely fashion e.g. letters going directly to med secs who sit on them for too long. If you know the patient won’t be seen for >10 weeks, why bother getting them on the system – this is the attitude in some cases at least!

With a sigh of relief, you’ve signed off your plans for 2013/14 (or at least you’re about to). Presumably, those plans provide levels of activity that the commissioner can afford, the provider can deliver, and that achieve the 18 week waiting times standards.

Or at least, they achieve those things on average. But what about next month?

The trouble is, it makes a big difference how that activity is profiled through the year. Even if everything goes according to plan, and demand turns out exactly the way you expected, you can still end up with capacity and waiting times problems when winter and the school holidays come around. Your plan should really profile your elective work across the year, to avoid things like trying to bring in lots of orthopaedics in the middle of January, while making sure you won’t breach 18 weeks during the temporary slow-downs.

The planning process already requires this, of course, with monthly activity trajectories to support the overall activity plans. But usually it is hard enough agreeing the overall plan, and the monthly breakdown is just rattled off pro rata to feed the beast. The last time I saw a serious attempt to do this properly in a spreadsheet, it was an Excel monster of 100,000 cells. So profiling activity through the year is a nice idea, but too hard to do in practice, is it?

Well it may be too hard in a spreadsheet, but it’s straightforward in Gooroo Planner. Just click the Profiling icon and it will chart your plan as week-by-week trajectories for activity, capacity and waiting times. It even shows total capacity and RTT waits too, and you can download all the detail for pasting into other documents.

Changing the profile is easy, and we’ve designed it for people who aren’t comfortable manipulating spreadsheet formulae – you can just click any week to change the profile, and immediately see the effects of half terms, Christmas, and pre-winter activity blitzes, right there on the chart. (Now is the ideal time to start planning for next winter, by the way; if you leave it until autumn it’ll be too late to front-load some surgery.)

Want to devolve this kind of planning to the Trust’s operational divisions? Easy; just share the master plan with them using Gooroo’s built-in collaboration tools, and let them edit their bits of it directly. That way they’re all using the same methodology, they’re all using the demand for patient care as their starting point, and they’re all working to the same corporate framework.

Want to collaborate between commissioners and providers? That’s easy too. Providers have all the data required and commissioners don’t, so the provider just pumps it into the model and shares it with the commissioner. That way, commissioners can take a private copy of the plan to test their own assumptions, and then both sides can track agreed changes in the master model with an audit trail every step of the way.

So it’s time to reset your assumptions, because planning is much easier, more powerful, and more collaborative than ever before. If you’d like to learn more about Gooroo Planner with a free on-site demo, just email info@nhsgooroo.co.uk

February saw a further 21 per cent fall in the number of patients waiting over a year in England, hot on the heels of a 22 per cent fall in January. Across the country there were only 665 one-year-waiters at the end of February, down a massive 88 per cent from 5,653 a year earlier. For the first time ever, no provider had more than 100 one-year-waiters on its waiting list.

Providers are under pressure to treat their one-year-waiters because, starting with the end of April figures, they face ‘zero tolerance’ fines of £5,000 per patient per month if they report anyone still waiting more than 52 weeks after referral.

The position on 18 week waits was broadly stable, with 92 per cent of the list waiting up to 16.4 weeks and comfortably achieving the 18 week target at national level. The total size of waiting list, if you strip out step-changes, was broadly in line with the seasonal profile of previous years.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

One more thing before we move on to the detail. You wait ages for a review of NHS waiting times and then two come along at once. These things really don’t happen very often (about once a decade) so if you have anything on your mind about how waiting times are measured then feel free to respond to the consultations by the National Audit Office and UK Statistics Authority.

England-wide picture

On the raw figures, the waiting list looks high for the time of year:

But if you strip step-changes out of the data (using the method explained here) then it doesn’t look out of line with previous years.

Admission rates continue to follow the pattern of previous years, despite the difficult winter.

One-year-waiters continue to fall rapidly, and we can expect even more dramatic reductions in the next couple of months as the zero-tolerance target comes in. Other long-wait measures remain steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, is holding steady.

Drilling down to specialty level, there is continued deterioration in orthopaedics and plastics, and in the more specialised services of neurosurgery and cardiothoracic surgery. General surgery has just scraped inside the 18 week target for another month.

The target must be met by every specialty in every provider in every month, and 85.2 per cent are succeeding, which is broadly stable from previous months.

Provider top ten

RJAH still has the longest ’92 per cent’ waiting times, and has the most one-year-waiters, but has gained some ground since the end of January. At number 2, Clinicenta have not improved their ’92 per cent’ waits, but they have cleared all their one-year waiters.

For the first time, no provider has more than 100 one-year-waiters on its waiting list. Those with the most are:  RJAH 98, Kings 73, Guys/St Thomas 44, East Kent 42, Royal Orthopaedic 35, Western Sussex 27, Brighton and Sussex 26, Southampton 26. Some 62 Trusts reported any one-year-waiters, down from 64 in January.

North Bristol and Bradford still aren’t submitting incomplete pathways data. North Bristol last submitted in July 2012, and Bradford in September 2012.

One provider dropped out of the top ten: congratulations to North Cumbria, whose improvement on ’92 per cent’ waits from 18.3 to 17.8 weeks has earned them a drop in the table from 10th to 34th place.

The 12-month statistics calendar has also moved to NHS England. The next figures (for the end of March 2013) are expected at 9:30am on Thursday 16 May 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick a Trust or independent sector provider, and get a full analysis of the pressures in any specialty, then all the detail is here. I’m afraid haven’t put the PCTs up this time because I had a software glitch overnight (and am hoping nobody will mind because they’ve all been abolished now anyway).

Where are the very-long waiters?

The following map compares one-year waits, 18-week waits, and total waits, with the values a year before. You can click the provider name to get a full analysis.

92 per cent of the waiting list within 18 weeks

The most meaningful (and, from April, the main contractual) waiting time measure is that 92 per cent of the waiting list (‘incomplete pathways’) must be within 18 weeks. So this map series shows how long 92 per cent of the waiting list has actually waited.

Unfortunately the mapping service I use has limited their free service to 250 lines of data, so I can’t map the specialty-level data any more. But you can download a table of all the detail here: map data

More and more NHS organisations are using Gooroo Planner, so we’re in a great position to invest heavily in making our software even better than before. Here’s a preview of what’s coming out in the next few months:

Integrated reporting

Currently you navigate around the main Report area using a menu of links. It’s easy to use, but we think it could be a lot better. So we’re going to turn it into a tabbed area that you can navigate around freely, without having to reload the main reporting table every time, or reselect services when editing or drilling down to week-by-week profiles.

Export to Excel

Sometimes you just want your main reports table on paper, or in a table that you can paste into a document. You can do that already, by dragging the mouse across the report table and then copying and pasting it. But that’s a little clumsy, so we’re going to build you an export to Excel button. It will download your whole report into a single Excel table, with all your formatting, sorting, filtering and subtotalling preserved. Then you can easily copy, paste, and print it from there.

Advanced filtering

A lot of people have asked for this, and here it comes. The main report table already has a simple but effective filter box, that narrows your table down to whatever you type in it. The trouble is that sometimes you get matches you don’t need, so if you type “ENT” then you’ll get the specialty, but those letters also appear in “inpatient” so you might get a lot else as well.

The solution will be an advanced filter that lets you choose exactly what you want to see, header by header. So if you want to see both of the specialties ENT and ophthalmology, and only daycases for each, then that’s exactly what you’ll get.

Video tutorials

Instruction manuals are so last century; today, you want bite-sized videos just a few minutes long to show you how to do things. Video is especially good for software tutorials, because it shows you exactly what happens, in context, without you having to wade through pages and pages of screenshots.

Unfortunately nearly all NHS organisations block YouTube (though even the Department of Health has a channel there), as well as other video-sharing, slideshow-sharing, and file-sharing sites. In fact, some NHS organisations automatically block any site that contains streaming video. Dear IT departments: is this really necessary? We’re trying to get some work done here.

Anyway, we’re determined to get video tutorials to you somehow, and here’s how we plan to do it.

First we’re going to set up a new subdomain (video.nhsgooroo.co.uk), and put all our video tutorials on there. So even if your organisation does automatically detect and block video streaming sites, only that subdomain should be affected. Then, because all the content is serious and work-related, you should find it easy to persuade your IT department to unblock it again. Look: no funny cat videos.

Secondly, in case that doesn’t work for everyone, we’ll be able to deliver those videos to your smartphone. This is a bigger task because we’ll have to rebuild much of our website onto a new platform that responds automatically to mobile screen sizes. But then at least you can be sure of accessing the videos somehow.

Official statistics aren’t perfect, and that goes for the waiting list too. Sometimes Trusts discover waiting lists that they should have been reporting, but weren’t. Sometimes they find problems with their data, take a ‘reporting break’ for a while, and then resume on a different basis. And data can also be discontinuous when Trusts are abolished and created, or when services shut down or move.

So stuff happens, and it all affects the reported number of patients on the waiting list. The question is: when you add up all these changes, could they explain the apparent growth in the English waiting list? Funnily enough it turns out that, yes, they could.

Here is the officially-reported number of patients on the English waiting list (count of incomplete pathways) since the 18-week target was achieved ‘properly’ in summer 2009. You may recognise this chart from my monthly reports on waiting times in England, and as you can see the red line is looking high for the time of year.

But if you trawl through all the detail at Trust-specialty level, and strip out any apparent step-changes in counting, the chart looks like this instead:

As if by magic, the increase has disappeared. It isn’t proof, but it’s enough to cast serious doubt on the apparent increase, and I think we can all be more relaxed about it. After adjustment, the size of the waiting list looks pretty stable year after year, and any increases and decreases are lost in the noise without any discernible trend.

Method

You may be feeling sceptical at this point, which is perfectly reasonable. So now I’ll explain exactly how I adjusted the official figures to produce the second chart, and you can make your own mind up about the conclusions.

Fans of statistical process control may be thinking of 3-sigma variations or CUSUM charting at this point, but the problem with those methods is that they all rely on deviations from an intended or mean central value. But the size of a waiting list does not have a central value, so we need to use a different approach. Instead I applied two rules to detect steps that may be caused by counting changes; either:

1) the reported list size falls to zero, or rises from zero, which should detect new or closed services and ‘reporting holidays’; or

2) the average of the next 4 months differs from the average of the previous 4 months by more than 2 standard deviations (where standard deviation is measured month by month over the whole time series), which should detect ‘newly-discovered’ waiting lists and major validation exercises.

The two tests were applied month by month to list size data from August 2009 to January 2013, at Trust-specialty level, which is the most granular data publicly available and therefore gives the best chance of detecting service-level changes. Steps in the data were detected in 2.4 per cent of months, which is equivalent to a step-change every 3.5 years at Trust-specialty level.

The data trawl was based on the current list of Trusts, so further adjustments were made for Trusts who existed in the March 2012 data but not the following month (principally pre-merger Barts). No Trusts disappeared from the data series in the month following March 2011 or March 2010.

If you have ever tried to detect anomalous deviations in time series data, you will know how frustrating it is. Sometimes your eye tells you there is a screaming change in the data, but your formula doesn’t pick it up. Other times your formula picks up a deviation that your eye tells you is just noise. The eye is very good at pattern-recognition, but it is also subjective, easily-led, and gets tired. So with 2,622 Trust-specialties to trawl, it’s better to let the computer do the work and hope the errors come out in the wash.

Let’s take a look at some examples of steps detected by the two rules. In each chart, the blue line is the list size (count of incomplete pathways) for one specialty in one Trust, and the yellow column indicates where a step up or down has been detected by the rules.

Here is a new Trust coming into existence:

Here the size of waiting list steps up, perhaps after the Trust discovered an unrecorded waiting list:

In this one, a Trust discovered a problem with its waiting list data, took a ‘reporting holiday’, and resumed reporting with corrected data:

I mentioned that sometimes the eyeball and the computer disagree with each other, and here are a couple of examples. Firstly, here is an example where the computer detected a step but the eyeball says it’s just noise:

And here is some data where the eyeball says this is a service that is being progressively shut down. The algorithm, however, doesn’t detect the early stages of the closure because the standard deviation is so high that the steps don’t exceed the two-sigma threshold, and only the final closure down to zero is detected.

To end the examples on a positive, here is some noisy data where no steps are detected by either the computer or the eyeball.

Whenever a step is detected, the later data is assumed to be correct, and all months prior to the step are adjusted by the size of the step. For instance, if the waiting list steps-up by 1,000 patients in June 2011, then all months prior to June 2011 are adjusted by adding 1,000 patients.

The total size of the adjustments across all Trusts and specialties is:

The adjustments made are shown by the green line and, as we saw, they are enough to put the waiting list on the same path as in previous years. Given that the total list size is a decent leading indicator of long-wait pressures feeding through, that would indicate that (at least so far) pressure is not building on the waiting list itself.

The constant caveat, of course, is that the list size does not tell the whole story because referral restrictions may be holding up patients before they get that far.

UPDATE: This methodology is now incorporated into my regular monthly analysis of the English waiting list, with a couple of differences. Firstly, independent sector providers will be included. Secondly, hospitals admitting fewer than 50 patients in the most recent month will be excluded. The overall conclusions remain the same despite the changes.

The genuine, externally-driven demand for healthcare is remarkably stable. But inside the NHS it doesn’t feel like that; managers are constantly responding to new pressures.

Sometimes it is a genuine and sudden spike in demand: an outbreak of flu for instance. Sometimes demand steps-up because of something the NHS has done (like start a new screening programme), which should be predictable.

But most of the time, in most services, nothing really changes very much. And yet the fire-fighting continues.

Why?

Let’s try a few scenarios and see if any of them sound familiar:

Scenario 1: The responsive clinic

The consultants’ clinic sessions haven’t changed in years. Nor have the clinic templates. The Choose & Book ‘polling ranges’ were set years ago to meet 18 weeks, and haven’t changed since.

Every now and again, staff notice that all the clinic slots have filled up so there’s nothing available on Choose & Book. They beg a willing consultant to run an extra clinic in 2-3 weeks time, and it fills up quickly with new Choose & Book patients. That takes the immediate pressure off, but patients are still booking right up to the end of the polling range.

Scenario 2: The helpful orthopods

Waiting times are a long-standing problem for orthopaedic inpatients, but the orthopods are usually quite flexible and manage to keep on top of it. Whenever the TCIs for the coming month are looking set to breach, the consultants manage to run some Saturday morning lists and avoid the crisis.

It costs an arm and a leg in overtime and bank staff, and the consultants are paid handsomely for the extra sessions, but it keeps a lid on it.

Scenario 3: The pragmatic plan

The operational managers know how many consultants they’ve got, how many sessions they’ve got, and how many cases they do in a session. So they multiply all that up, then that’s their plan for next year. Yes, some services are struggling with 18 weeks, but there’s no point in promising the commissioners extra activity when you don’t have the resources.

The solution

All those scenarios have one thing in common: baseline capacity is not based on demand.

There will always be some form of mismatch between capacity and demand, because capacity comes in chunks (consultants, sessions, beds) and demand is more continuous. Over time, the gap between capacity and demand will drift, until after a few years it becomes quite pronounced.

The result is that some elective services have a steadily growing waiting list (and periodic waiting times crises, tackled with expensive ‘extra’ sessions, as they bump along under the target). Meanwhile, other elective services have a steadily shrinking waiting list and either run out of patients or (more likely) slacken off their activity by running short sessions.

The solution, obvious as it may sound, is to align baseline capacity with recurring demand. Then those expensive ‘extra’ sessions are only needed for genuine non-recurring work, and you can pull resources out of any areas that are quietly enjoying a bit of slack.

It isn’t rocket science, but it is fiddly because you have to take a lot of things into account. It’s best to let a professional model like Gooroo Planner take care of it all for you.

You have, I hope, just signed-off with commissioners your plans for 2013/14. This is the perfect time to cross-check them. You’re going to need an internal plan you can believe in, based on what you really think is going to happen to demand, taking account of the knock-ons from outpatients to electives, and broken down week by week so you can meet your objectives all the time and not just at year-end.

Get in touch on info@nhsgooroo.co.uk and we’ll be happy to drop in and show you more. If you decide to go ahead, we can cross-check your plans as part of the initial induction programme.