Archive for the ‘Waiting time targets’ Category

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!

Some of the differences between Scottish and English waiting times are pretty obvious. England has three 18-week referral-to-treatment targets and a 6-week diagnostic wait (pp.38 & 58), whereas Scotland has one 18-week referral-to-treatment target, a 6-week diagnostic wait, a 12 week inpatient/daycase Treatment Time Guarantee, and a non-legally-binding 12 week outpatient wait (p.5). Already we can see that it’s quite complicated in England, but even more complicated in Scotland.

If you dig into these targets you find the rules are different too. The differences are pretty big, and many patients who would have a right to short waiting times in England, enjoy no such guarantees in Scotland.

For instance, if you are referred to an English hospital then they have to accept the referral and treat you (unless they don’t provide that kind of care, or you agree to be treated elsewhere) (pp.7-8). But in Scotland the hospital can routinely send its patients just about anywhere it likes (p.16), even if the destination is way outside the boundaries of its Health Board; any patient who refuses can be taken off the waiting list or have their ‘clock’ reset to zero (p.17). In case you think that such long-distance transfers might be a rare event, Scottish Health Boards have regular arrangements to send increasingly large numbers of waiting list patients to the Golden Jubilee National Hospital west of Glasgow, even from as far away as Orkney (p.5).

You have to be ready at short notice in Scotland too, because the NHS considers seven days’ notice to be a “reasonable offer” (p.15), compared with three weeks in England (pp.34-35). (To protect urgent patients, hospitals can offer shorter-notice appointments in both nations, and patients are free to accept or reject them without penalty.)

And you should avoid changing your appointment in Scotland, even if you give them plenty of notice, because the hospital can use that as an opportunity to reset your clock to zero; if you change your appointment three times, they are normally expected to send you back to your GP (p.19). There are no such sanctions for changing appointments in England even if you give only short notice (p.28). In both nations, though, you can be taken off the list and sent back to your GP if you fail to attend your first outpatient appointment without giving notice (i.e. you ‘DNA’) (p.20, p.28).

If you are ever unavailable for treatment, either for medical or social reasons, then in Scotland your ‘clock’ is paused (p.22-25). This rule was very heavily applied (pp.10, 19) until a recent clampdown. In England the new main target (based on incomplete pathways: p.58) does not allow clock pausing at all, although clock pauses were certainly allowed and used against the previous main target.

Then there are patients who are completely excluded from the targets. For obvious reasons, both England and Scotland exclude obstetrics from their waiting time guarantees. If you are waiting for an organ transplant, then the wait for the organ itself is excluded in both nations. And if you want to become pregnant then assisted reproduction is covered in England, but not in Scotland. (p.13-4)

Both nations have short-wait guarantees for cancer outpatient appointments and initial treatment, but the English guarantee covers all cancers (pp.38-40) while in Scotland there are exclusions covering several cancer types (pp.15, 25-26). If you are having a course of cancer treatment then, in England, you are guaranteed your subsequent treatment within time limits, whether it’s surgery, chemotherapy or radiotherapy (pp.39-40); but there are no such guarantees in Scotland (p.5).

There are different exclusions in diagnostics as well. Scotland applies the 6-week guarantee only to eight key diagnostic tests (p.14), which means that English (but not Scottish) patients are guaranteed a 6-week wait for DEXA and various kinds of physiological measurement (p.8). However in both nations the diagnostic wait is part of the 18-week referral to treatment wait, so this may not make a massive difference in practice.

Why are the English rules apparently so much more patient-friendly and inclusive than the Scottish ones? I think the answer was right at the start: the nature of the waiting times targets.

In England, the overall targets have a tolerance, for instance that 92 per cent of patients on the waiting list must be within 18 weeks. That leaves an 8 per cent margin for the odd exceptions (and there will always be exceptions).

In Scotland, though, the legally-binding 12 week Treatment Time Guarantee is a 100 per cent target. There will still always be exceptions, so they must be allowed for in the rules; which means you need lots of rules.

Personally, I think the English approach is the better one. (And in case anyone north of the border is starting to suspect a national bias, I should say that I am Scottish and was born and brought up in Scotland.) Hard cases make bad law, and trying to define all the reasonable exceptions in the rules is inevitably going to be complex and imperfect. Better simply to allow a tolerance in the target and let the rules include everybody.

Monitor is out to consultation on how it should judge NHS Foundation Trusts, and performance against the “18 weeks” targets is part of the mix. The deadline for responses is 4 April 2013, so this is a good opportunity to influence their proposed approach and fix its unintended consequences.

Monitor’s proposed approach

The place to go is page 78 of the consultation document. There are 28 targets and indicators, ranging from waiting times to C. Diff. to medication errors. Monitor propose that:

NHS foundation trusts failing to meet at least four of these requirements at any given time, or failing the same requirement for at least three quarters, will trigger a governance concern, potentially leading to investigation and enforcement action.

and each of the three 18-weeks measures is included as a separate indicator in the list:

• Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted: threshold 90%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted: threshold 95%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an
  incomplete pathway: threshold 92%

accompanied by the following note:

18 weeks referral to treatment: Performance is measured on an aggregate (rather than specialty) basis and NHS foundation trusts are required to meet the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure for the purposes of the Risk Assessment Framework. Failure in any month of a quarter following two quarters’ failure of the same
measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. Failure against any threshold will constitute a governance failure. The measures apply to acute patients whether in an acute or community setting. Where an NHS foundation trust with existing acute facilities acquires a community hospital, performance will be assessed on a combined basis.

Monitor will take account of breaches of the referral to treatment target in prior quarters (i.e. under the Compliance Framework) when considering consecutive failures of the referral to treatment target under the Risk Assessment Framework

Response

As usual with consultations, it isn’t always easy to tell which of the consultation questions is the right one for any particular issue. For this response, I’ve gone for Question 10:

Chapter 4 Question 10: Do you agree with the proposed approach to downgrading the governance rating – and ultimately finding a foundation trust in breach – as a result of either unresolved concerns for significant periods or concerns across multiple categories?

No (with regard to the “18 weeks” access targets)

Please provide more details:

Appendix A includes the three “18 weeks” access targets, and each target is considered independently when assessing the number and duration of failures. Unfortunately this approach has unintended and undesirable consequences.

Consider the following scenario : a Foundation Trust has developed a backlog of over-18-week waiters on its waiting list. Because of this backlog, it starts to breach the incomplete pathways target.

The most desirable cure for the backlog is to treat those long-waiting patients as soon as possible. Unfortunately, the current approach deters the FT from doing so.

The reason is that if the FT admitted all those over-18-week waiters, it would be likely to incur a second breach (against the admitted patients target). FT Board members have a strong incentive to avoid this further breach (especially if they are also breaching any other measures) by using a well-established tactic: taking care to admit only one long-waiter in every ten admissions. This severely restricts their ability to do the right thing and treat the backlog, and the proposed approach is therefore a perverse incentive. Put another way, for every long-waiter they admit, they must find nine short-waiters to admit out of turn; this is unfair to patients, and all that queue-jumping pushes up the longest waiting times.

So what should be done?

Ideally the admitted and non-admitted targets would be deleted. But I anticipate that this suggestion might not be acceptable, because both of those targets are currently specified in the NHS Standard Contract 2013/14 as well as the regulations underpinning the NHS Constitution.

So I would like to propose an alternative solution: that the three 18-weeks targets should be lumped together into a single-failure bundle. So a failure against any (or all) of them would only be one failure in total. Then, if an FT is breaching on incomplete pathways, it would not incur any further breaches by treating its long-waiters, so the perverse incentive is removed. The intended incentive (to avoid long-waiters building up in the first place, monitored across all three measures) is nevertheless preserved.

Scotland is getting results from its new legally-binding Treatment Time Guarantee (TTG), which guarantees that eligible inpatients and daycases will start treatment within 12 weeks of being added to the waiting list. The number of over-12-week-waiters on the list fell, for the first quarter in nearly 2 years, to levels not seen since December 2011.

However over-12-week waiters on the outpatient waiting list, which are subject only to a non-legally-binding target, continue to rise rapidly.

All data in this post comes from ISD Scotland, and I have excluded Lothian Health Board throughout (they would totally dominate the picture otherwise: they were caught with terrible long-waits but have been turning things around since).

If you do look up the original data tables you should be aware that the inpatient & daycase data is rather confusing at the moment. The TTG only applies to those patients added to the list after 1 October 2012 (and there are exclusions), so in the following chart I have added together the pre- and post-October data series in the hope of getting (reasonably) consistent data.

In a very welcome last-minute change, the Commissioning Board has just amended the ‘final’ NHS Standard Contract 2013/14 and given top priority to clearing the long-wait backlogs on England’s NHS waiting lists.

There has been a dramatic turnaround in waiting times penalties during the drafting of this Contract. The ‘near final’ draft, published just before Christmas, perversely penalised hospitals for treating long-waiters, but not for allowing long-wait backlogs to build up in the first place (though it did introduce the new backstop penalties for having one-year waiters on the list). The supposedly-final version of the Contract, published on Monday, added new penalties for building up long-wait backlogs but gave them little weight. Today’s version of the Contract correctly slaps the highest penalties on the backlog, and reduces the legacy penalties for treating long-waiters.

As the final Contract stands now (Particulars p.58), any hospital specialty that allows more than 8 per cent of the waiting list (incomplete pathways) to exceed 18 weeks will be subject to a sliding scale of penalties up to 2.5 per cent of elective revenue. The older targets linger on, so that if they try to clear their backlog, and more than 10 per cent of the patients they select for admission have waited over 18 weeks, they face penalties up to 1.875 per cent of revenue. That is perverse, but it isn’t as bad as it sounds. Because the penalties are applied monthly, it is much cheaper to clear the backlog and pay the smaller penalty temporarily, than to let the backlog fester and pay the higher penalty indefinitely.

This fundamentally changes the incentives around waiting times, putting the emphasis firmly on avoiding backlogs rather than managing them. Nevertheless providers need to be aware that it is perfectly possible to achieve the ’92 per cent incomplete pathways’ target every month, and still consistently breach the ’90 per cent admitted patients’ target. When planning the list size that is consistent with sustaining all the 18-weeks targets (as sensible specialties do) it it best to plan against the most demanding one.

All this has felt like a very long journey. Waiting-list-based targets were first announced by Andrew Lansley as long ago as 17th November 2011, but disappointingly weren’t written into the subsequent NHS Standard Contract. Although the Mandate mentioned the waiting-list-based target as well as the treated-patient-based ones, it wasn’t clear about their relative priorities (and the waiting-list-based target was at a disadvantage because it wasn’t enacted in legislation until last week). But now it’s done, and the waiting-list-based targets have finally reached the top of the pile.

Why did it take so long? The main justification is that the incomplete pathways (waiting list) data is much more error-prone than the treated-patients data. When the last Labour Government introduced referral-to-treatment waiting times targets, it was a massive technical challenge to stitch together the waiting times of outpatients, diagnostic patients, and admitted patients, which in most hospitals are held on separate computer systems. It is easier to link the waiting times together towards the end of the patient pathway, once their activity has been coded from the early stages, than to link it together while they are still partway through. Nevertheless, data on incomplete pathways has been collected since August 2007, so I have to say I think the change could have been made earlier.

But we are there now, and it looks pretty good. The main penalties discourage over-18-week backlogs from building up, and in the coming months this should lead to further satisfying falls in long-waiters. We also have hefty zero-tolerance penalties where any patient is still waiting a year after referral, which should at long last bring those extreme long-waits to an end. With the focus returned to the waiting list where it belongs, providers are now encouraged to focus on the fundamentals: keeping the list size down and scheduling patients in the right order. That’s better for patients, better for the service, and much less confusing for the public.

The final 2013/14 NHS Standard Contract has now been published, with a small but welcome change in the penalties for breaching the 18 week waiting times targets. In the previous “near-final” draft there were penalties for treating long-waiters, but none for allowing long-waiters to build up in the first place.

In the final version (Particulars p.58), any specialties with large 18-week backlogs face new penalties of up to 0.625 per cent of elective revenue every month. But the penalties for admitting long-waiters also remain in force: if a specialty admits its long-waiters instead of keeping them waiting, it faces penalties of up to 2.5 per cent of elective revenue every month (although those higher penalties would only apply while the backlog is in the process of being cleared).

It is welcome that the Commissioning Board has introduced penalties for having 18-week backlogs. This tackles the root of the problem, and rightly draws attention to the waiting list itself instead of those patients lucky enough to be selected for treatment. It may also strengthen the hand of providers who wish to treat extra patients in order to control the size of their waiting lists.

However at 0.625 per cent the penalties are rather small, and the regime is now very complex with contradictory penalties applying across the three 18-week targets. This makes it difficult for people who are not immersed in the subject to understand and interpret the numbers (a problem that has extended right up to the Prime Minister). The continued penalties for treating long-waiters are perverse, and it would be better to drop them and simply monitor completed patient pathways as a means of catching data errors and ‘gaming’.

So it’s a small and rather slow step, but at least it’s in the right direction.

How should the NHS respond to the new target regime? Fundamentally, waiting times are a function of the size of the waiting list and the order in which patients are scheduled. It is no longer possible for specialties to avoid penalties simply by admitting 9 short-waiters for every 1 long-waiter, and instead they must address the fundamentals: by knowing how small their waiting list needs to be to sustain 18 weeks, and keeping it below that size; and by scheduling patients according to the well-accepted principles that urgent patients should be treated quickly and other patients should be treated broadly on a first-come-first-served basis.

If the new penalty regime achieves a widespread return to those fundamentals, then it will have succeeded.

The new NHS Commissioning Board is fumbling the ball on waiting times, by continuing to penalise hospitals who treat their long-waiting patients, but not if they keep them waiting.

The perverse penalties are in the near-final draft of the 2013/14 NHS standard contract (Section A p.62, footnote 1), and apply to the targets that 90 per cent of admitted patients (and 95 per cent of non-admitted patients) must be selected from the under-18-week portion of the waiting list. There are no penalties for building up backlogs of over-18-week waiters.

Hospitals are, however, prevented from building up indefinite backlogs by a very-welcome new ‘zero tolerance’ penalty of £5,000, per month, for every patient reported on the waiting list who has waited more than 52 weeks since referral (Section A p.45). This at least puts a backstop on backlogs, albeit at the extreme end.

If these 18-week penalties remain unaltered in the final Contract, it represents a major setback for waiting times policy. The direction of travel since November 2011 has been to move away from punishing hospitals who treat their long-waiters, towards penalties that prevent those long-waiters from building up in the first place. That is why the incomplete pathways (i.e. waiting list based) target was introduced in the Operating Framework 2012/13 (2.31), and why new regulations for the incomplete pathways target come into force from 1st February 2013 (see regulation 45(3)).

The targets in the current draft Contract are a bit like lobster pots: you can get into them, but it’s hard to get back out again. It’s all very well saying to a hospital “well, you shouldn’t have built up that backlog in the first place”, but once the backlog exists it is hardly constructive (or good for patients) to insist that every time they admit a long-waiting patient they must also find room for 9 short-waiting patients to be admitted out of turn. Now that data collection for incomplete pathways has improved, it makes sense to target the backlog directly and phase out the perverse incentives.

It will be interesting to see if the final version of the Contract puts things right. If it doesn’t, then the targets must be deliberate and we would have to ask: why? None of the possibilities that I can think of are terribly flattering to the Commissioning Board, so let’s give them the benefit of the doubt and wait to see what the final Contract says.

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

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

Because this latest data release included a lot of revisions of previous months’ data, it’s taken a bit longer than normal to do all the crunching. But all revisions have now been fully taken in, and here is the latest version of the Gooroo NHS waiting times fact checker

Where are the very-long waiters?

One-year-waiters have fallen dramatically, and the end is (perhaps) now in sight with the introduction of “zero tolerance” penalties in next financial year’s Contract. Until all the one-year-waiters are finally treated, however, they are going to carry on getting the top billing here.

It is nothing short of a disgrace that some providers are still keeping patients waiting more than a year for treatment, while nearly everybody else is being treated so quickly. Yes, in some places we’re down to the difficult ones, including some who need ITU / two surgeons / special equipment / whatever, but the NHS has made a promise to these patients and it’s time to deliver on it.

Check out the Robert Jones and Agnes Hunt Orthopaedic Hospital, for instance: they have 100 patients waiting over a year in Orthopaedics, which is a decent chunk of the 1,147 one-year-waiters across England; and yet (helped along by a lot of clock-pausing) they’re still “achieving the target” that 90 per cent of admitted patients should have waited less than 18 weeks!

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

Other maps you might find useful:
All specialties together, by NHS/IS provider (same as map above)
Each specialty separately, by NHS/IS provider
All specialties together, by PCT (i.e. population basis)
Each specialty separately, by PCT

The 92 per cent target

The most meaningful of the 18 week targets 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.

Each specialty separately, by NHS/IS provider
Each specialty separately, by PCT (population basis)

Where are the most ‘clock pauses’?

This map shows where the greatest amount of clock-pausing is happening, measured by the difference between 90th centile adjusted and unadjusted waiting times.

Why this focus on clock pauses? Because the best way to tackle long waits in the NHS is to address the two root causes: waiting lists that are too big, and sub-optimal patient scheduling. If services come to rely on clock pauses to achieve their targets month after month, then that deflects attention from those root causes. If a service gets to the point where it is over- or mis-using clock pauses then that is unfair to patients, and likely to end in crisis when the position becomes unsustainable. So the intention of this focus on clock pauses is to shine light on them so that they are not over-used, and the root causes of long waits are addressed instead.

Clock pauses are applied by the provider, so here is a map showing where clock pauses have the greatest effect at Trust-specialty level:

 

The NHS in England held its position on referral to treatment (RTT) waiting times (according to the newly-released data for November 2012), with small gains leading to new record-bests for long-waiters on the national waiting list. The total size of the waiting list came down slightly, but remains somewhat above the seasonal trend (though not enough to be a cause for concern, yet).

One-year-waiters continue to fall, reaching a new low of 1,147. From April, these one-year-waiters will attract penalties of £5,000 per patient for every month they remain on the list, so Trusts will be making great efforts to treat or discharge them before the fines kick in. The number of over-18-week waiters also fell to a new record low of 135,095 (compared with 218,290 a year before).

All this data comes from the Department of Health. At the same time as the November 2012 data was released, they also released revisions for 6 months worth of earlier data. This blog post does not take in those revisions because they’ll take a bit longer to analyse, but I will take in the revisions before publishing our waiting times fact checker and the local analyses over the weekend. (Revisions don’t normally affect the national statistics very much, though they can make a big difference to provider-level data.)

England-wide picture

The waiting list has finally started shrinking, as it normally does at this time of year, but remains above the level of recent years. Nothing (so far) to worry about though.

 

Admissions are bang on track – no sign of austerity causing any drop in admitted activity.

 

Long-waiters continue their very-welcome fall. At this rate I’ll need to extend the scale on this chart for next month’s data.

 

The target that 92 per cent of the waiting list should be within 18 weeks is still comfortably met at national level.

 

Orthopaedics scraped inside the “92 per cent of the waiting list within 18 weeks” target for the first time in October, and missed the target equally narrowly in November. In better news, Neurosurgery is really getting sorted out now, and is no longer an outlier.

 

The “92 per cent of the list within 18 weeks” target must be met by every specialty, in every provider, in every month. Success continues to creep up, with 87 per cent of provider-specialties achieving the target in November.

Provider top ten

The RJAH and Clinicenta remain stubbornly at the top of the sin list for November, far ahead of other long-waiting providers.

North Bristol and Bradford failed to supply incomplete pathways data (again), so they are not included in the table.

From April there will be severe ‘zero tolerance’ penalties of £5,000 per over-one-year waiter every month, so any providers who are still keeping patients waiting that long will be wanting to get them in. In November the biggest one-year backlogs were 137 at King’s, 101 at RJAH, 95 at Newcastle, 92 at Nottingham, 83 at Guy’s and St Thomas, 48 at Brighton, 40 at West Sussex, and 39 at the Royal Orthopaedic.

 

 

The 18-week statistics for December 2012 are due out at 9:30am on 14 February 2013.

The English NHS has spectacularly reduced the number of patients waiting over a year for treatment: from over 20,000 in September 2011, to below 2,000 a year later. At the time, I commented that the reduction probably owed more to waiting list validation than to real patients being treated (but that didn’t stop it being a fantastic achievement).

Although I was pretty confident it was mostly validation (based on conversations with Trusts who were trying to clear their one-year backlogs) I confess I hadn’t actually analysed the published RTT data around this. So now I’m going to put that right, and look at the numbers properly.

It turns out that about 58 per cent of over-one-year waiters cleared since September 2011 cannot be accounted for in the figures for admitted and non-admitted patients. If most of the non-admitted patients were also validations, then up to 81 per cent of the reduction would be the result of data cleaning. So probably the true figure is somewhere in between, with around two-thirds or three-quarters being validation, and about one-quarter or one-third being real patients.

But dig a little deeper and a more interesting story emerges. Validation played the biggest role early on, and especially in the dramatic fall from 20,097 to 11,132 one-year-waiters that happened in October 2011. Since then validation has continued to play a large part, but more evenly balanced with real patient treatments.

Here’s a chart showing what happened:

The green line shows the over-one-year waiting list (i.e. the number of 52-week-plus incomplete pathways) at the end of each month. The columns show how many over-one-year patients had to be cleared from the list during each month, and how much of this is accounted for by the non-admitted and the (unadjusted) admitted patients data.

Let’s dig a little deeper into that October 2011 validation exercise. The accounts work something like this:

Opening balance of over-52-week waiters at the end of Sept 2011: 20,097

Patients joining the over-52-week cohort in Oct 2011, who had already waited over 47 weeks: ~5,526

of whom some were removed as admitted and non-admitted: ~407

Which gives us a potential closing balance of over-52-week waiters at the end of October of 25,216

Now the actual closing balance of over-52-week waiters at the end of Oct 2011 was 11,132

So the total number removed at 52-weeks-plus in October must have been: 14,084

We can account for some of these in the published RTT data:

Unadjusted admitted over-52-week patients in Oct 2011: 956

Non-admitted over-52-week patients in Oct 2011: 1,064

Leaves the number of over-52-week removals unaccounted for in Oct 2011: 12,064 (86 per cent).

The pressure on one-year waits is going to ramp up in the coming months, and there is the tantalising possibility that the new “zero tolerance” penalties may finally bring one-year waiting to an end. This is important: even if the waiting list is still full of data errors, there will inevitably be some real patients among them who need to be identified quickly and treated (just as some 9,075 real one-year-waiters have been admitted since September 2011).

The new “zero tolerance” penalties are being applied from April 2013 and they are severe: a £5,000 fine every month for each 52-week-plus waiter on the list (see Section A schedule 4B on p.45). Even for expensive procedures like joint replacements, clearing the one-year-waiters is now a must.