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Posts Tagged ‘clinical priorities’

The Department of Health’s draft Mandate to the new NHS Commissioning Board was published last week, and it’s bad news for anybody hoping for a bit of common sense on the 18-week waiting times targets. All three targets are being retained: that’s one target telling hospitals to treat their long-waiting patients, and two targets punishing them if they do.

The good news is that this is a consultation draft, so you have until 26th September to tell the Department of Health why they should reconsider. As usual, with government consultations, you have to find a way to fit your comments into a pre-defined set of strangely-tangential questions, and in this case the one to use is question 3: “Are the objectives right?”.

I am sure that staff in many Trusts will be able to provide the Department with plenty of examples from their own experience of how the offending targets have distorted patient care, confused and misled stakeholders on the waiting times position, and resulted in unfair criticism and financial penalties, when all they are trying to do is the right thing for patients.

Here is the response I am submitting:

Question 3. Are the objectives right? Could they be simplified and/or reduced in number; are there objectives missing? Do they reflect the over-arching goals of NHS commissioning?

Objective 10 specifically mentions three service performance standards for referral-to-treatment (RTT) waiting times. An NHS Trust with few long-waiters will achieve all three performance standards, and one with many long-waiters will not. However that does not mean they are all good standards to use, and the use of all three is already having unintended consequences for patients in those parts of the NHS where a backlog of long-waiters has built up.

Specifically, two of the performance standards (that 90% of admitted and 95% of non-admitted patients must start treatment within a maximum of 18 weeks from referral) are often detrimental to waiting times performance, undermine the ability of the NHS to deliver the NHS Constitution right to treatment within 18 weeks, and are unfair both to patients and to NHS Trusts; these two standards should be omitted. The third RTT standard (that 92% of incomplete pathways should have been waiting no more than 18 weeks from referral) should be retained.

The following example illustrates the point.

Trust A has developed a backlog of patients on its waiting list who have already waited over 18 weeks. The Trust does not want to have a backlog, and notes that the NHS Constitution right to treatment within 18 weeks, the incomplete pathways performance standard, the accepted principle that patients with similar clinical priority should broadly be treated on a first-come-first-served basis, and the wishes of clinicians and managers alike, all point towards a clear and simple solution: treat the over-18-week waiters and thereby clear the backlog.

However Trust A is restricted from doing so by the admitted patients performance standard, which stipulates that 90% of admitted patients must be selected from those who have waited less than 18 weeks. (The performance standard for non-admitted patients has exactly the same effect, though in practice it is less likely to be the stumbling block.)

The admitted patients performance standard has a number of effects:

1) In order to clear 100 long-waiting patients who have already breached 18 weeks, the Trust must at the same time admit 900 short-waiting patients whether their clinical priority justifies it or not (and in most cases it will not). This queue-jumping is unfair to the long-waiting patients.

2) This queue-jumping also pushes up maximum waiting times (as queue-jumping does in any queue) thereby making the long-wait backlog worse than it would have been without the queue-jumping. The number of over-18-week waiters will therefore be much higher than it would have been, if the Trust had been allowed to treat non-urgent patients in date order. This undermines the NHS Constitution right to treatment within 18 weeks.

3) Put another way, the Trust is only able to clear the backlog slowly, because it is only allowed to devote 10% of its activity to the long-waiting backlog. If this restriction were lifted, it could devote all its non-urgent capacity to the backlog (typically between 50% and 95% of activity depending on the number of urgent patients in the casemix) and clear it much more quickly.

4) The Trust Board’s monthly Performance Report monitors all three performance standards, but a majority of Board members have a limited understanding of how the standards act in opposition to each other. This leads to poorer monitoring and decision-making than if just one performance standard, whose effect is intuitive, were monitored.

5) Statistics are collected and published nationally based on all three performance standards, which leads to misunderstandings about the NHS’s waiting times performance by the general public, journalists, and politicians. Such misunderstandings have in the past reached the highest level: exchanges between the Prime Minister and Leader of the Opposition at Prime Minister’s Questions have on occasion assumed that an increase in the number of long-waiters being treated is a bad thing, when in fact it resulted in a reduction in the number of long-waiters still waiting which is a good thing.

In contrast to the admitted and non-admitted performance standards, the newer standard (that 92% of patients on incomplete pathways should have been waiting no more than 18 weeks from referral) does not similarly frustrate good waiting list management, and should therefore be retained.

It may be that the admitted and non-admitted performance standards were included in Objective 10 because they are referred to in directions 2 and 6 of The Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010, which were intended to support the 18 week rights in the NHS Constitution. For the reasons given above they are poor instruments for delivering that intention, and the directions should therefore be amended to omit reference to the admitted and non-admitted performance standards, and refer instead to the 92% incomplete pathways standard.

Imperial College Healthcare NHS Trust is in the news, with startling reports of a breakdown in record-keeping that resulted in patients waiting up to 2-3 years. Some of the patients who got lost in the system were suspected cancer referrals who the Trust is still trying to locate, months or even years later. It has been a horrible, stomach-churning failure.

To their credit, Imperial seem to be sorting things out pretty quickly: fixing the data, validating the waiting list, following up patients they are concerned about, clarifying scheduling procedures, and strengthening planning, all with external assistance and oversight. I don’t have inside knowledge of the actions they are taking, but it does look from the outside as if they are doing what you would expect.

Looking more broadly, how could the NHS become more resilient against this kind of failure? How can we make sure it never happens again and, if it does, that it is caught much more quickly to limit the damage?

Ultimately the answer is for any kind of waiting list to be regarded culturally as a sign of failure by the NHS, and to make involuntary waiting a thing of the past. But well before we reach that happy state there are more immediate and practical things we should do:

The first step is to simplify dramatically the reporting and targeting of waiting times. In common with most Trusts, Imperial’s scorecard in November 2011 (the last before their reporting break) tracked no fewer than eleven measures relating to the 18 week targets. Only one of those measures related to long-waiters still on the waiting list, and it was the second from last item. What were the other ten? Eight related to other waiting times targets set by the Department of Health, and the remaining two were Trust measures that simply tracked the numbers of patients being treated.

This proliferation is completely unnecessary. Get the waiting list right, and all the other measures take care of themselves. The Department of Health accepts the logic of scrapping the admitted and non-admitted targets, so let’s just do it. Then Imperial and everyone else can boil their 18 week reporting down to a single measure: the 92nd centile waiting time for incomplete pathways, so that Boards can see right away when things are going pear-shaped.

The second is to put an end to one-year waits. Patients don’t know where they stand with a 90 per cent guarantee (they are left wondering: am I one of the 10 per cent?). But if they know that nobody waits longer than a year then something is definitely wrong if they have. A one year limit works for hospitals too: if no patient ever waits longer than a year then systems are unlikely to slip for more than a few months (at the outside) before someone notices.

Thirdly, we can improve the tracking and management of the most important patients on the waiting list: no, not the imminent 18-week breaches, I mean patients with a high clinical urgency. There is a data field in each PAS system for recording the urgency of every patient on the waiting list: two week wait, urgent, or routine;  but in many hospitals this field is poorly used. Using it consistently would strengthen waiting list management and reduce the risk of urgent patients being delayed.

Finally, and in the longer-term, we can increase resilience by strengthening patients’ expectations and involvement during their waits. To their credit, the Government have made a start on this with the Operating Framework requirement to publicise to patients the 18 week guarantee. But these generalities are not specific enough: even BT do better, with regular personalised text updates on the escalation and fixing of the fault on your line. If patients were kept closely in touch with progress on their appointments, then they would be better placed to catch the ball if it dropped. The usual system of fire-and-forget referrals, “you’ll get a letter” hand-offs, centralised complaints procedures, and all the rest is too distant and siloed and we can surely involve patients in a more predictable and personal service.

How pressing is all this? Around England, and particularly in London, there are plenty of hospitals reporting dozens (even hundreds) of patients still waiting more than a year after referral. How sure can we be that nothing similar is happening at any of them, or that none of those patients are waiting even longer than the 2-3 years found at Imperial?

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 rob.findlay@nhsgooroo.co.uk

Getting ready

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

They’ve been a mainstay of waiting list management for a quarter century, and seen the NHS through the most spectacular reductions in waiting times in its history. They are breathtakingly simple in concept, and easy to implement in practice. They are already understood and embedded throughout the NHS. Why, then, do patient tracking lists need to change?

PTLs are also known by various other names that share the same initial letters (primary, patient, priority, tracking, treatment, targeted or targeting are common substitutes). They work like this. Draw up a list of all the patients who are going to breach your waiting times target in the next few weeks. Then you make sure they are treated before they do. Simple as that. What could possibly go wrong?

Well, quite a lot actually. Let’s say your target is 18 weeks, but your waiting list (at subspecialty level) is small enough to achieve 12. What waiting time do you achieve in practice? If you rely on PTLs then you’ll probably stay at 18 weeks, with managers firefighting imminent breaches week by week. Why? Because PTLs only work at the margins, so non-PTL patients (most of them) are not being managed systematically. Some patients get treated quickly, while others end up on the PTL.

Things get worse if the waiting list grows. If 18 weeks is achievable, but only just, then it becomes really hard to find slots for all your PTL patients: too many short-notice slots are already filled with non-PTL patients being booked out of turn (even if they aren’t urgent). So you end up on the familiar trail of begging consultants to squeeze PTL patients onto lists, buying extra sessions on a Saturday, persuading patients to transfer to the private hospital down the road, and even (though you hope it will never come to this) finding it difficult to treat urgent patients safely. Failure remains likely despite the effort and expense.

What if your PTL is too big to sustain 18 weeks? Much the same, except that now sustaining the targets is impossible. But you can’t tell from the PTL.

It isn’t all doom and gloom with PTLs. They’re a lot better than having no system at all. That is pretty much what was happening before PTLs were invented in the late 1980s, when inpatients waited years for treatment. But it’s pretty clear that we can do a lot better.

Now we can put an end to managing at the margins and in batches, to tying up managers’ time in endless firefighting, and to limboing under the target when much shorter waits are possible. Now we can move towards systematically managing all waiting list patients continuously by the booking clerks and via choose and book, to create an “active PTL”.

The active PTL rules aren’t complicated. In summary: urgent patients are booked as late as is safe (cancelling a routine patient if necessary); cancelled patients who need rebooking are booked into the next available slots (and in a fully booked service have access to urgent slots to avoid them going all the way to the back of the queue); new routines are offered the next routine slots; and if a short-notice slot is at risk of being wasted, then fill it.

By getting the booking right, the active PTL will consistently achieve the shortest waiting time possible. That waiting time might be eight weeks, or 18 weeks, or even 28 weeks. It all depends on the size of the list.

Ah, the poor waiting list. Her younger sister, waiting times, has been the sexy one these past few years and the fusty old waiting list hasn’t had much attention. So let us remind ourselves that the size of the waiting list is absolutely key: if it’s too big, then short waiting times are impossible, no matter how good your booking practices.

It’s about time waiting lists came back into fashion. Every subspecialty should know, for each stage of the pathway, how small their waiting list needs to be to sustain their waiting times targets. If the waiting list gets too big then it is time to take action.

That’s the funny thing about waiting times. Tackle them directly and you get all sorts of unintended consequences. But do it indirectly, via the list size and booking rules, and you’ll have them nailed.

First published in the Health Service Journal

The Government has listened, understood, and acted. The new RTT waiting times target is aimed directly at cutting the backlog of long-waiters, and elbows aside a target regime which actually punishes hospitals for treating long-waiting patients. The change, long called-for in this blog, is very welcome.

But no target is perfect. Targets always create problems of their own, distorting incentives and encouraging undesirable behaviours. Now that the perversities of the current regime have had their day, can we predict the nasties that the new target is going to throw up?

Happily, we don’t need to pull out our crystal ball. The new target is similar enough to the maximum waiting time targets of the 1990s that we just need to cast our minds back a few years. The two biggest problems then, and in the future, are likely to be distorted clinical priorities and hidden waiting lists.

Distorted clinical priorities

Point a TV camera at any NHS manager, and ask them: which is more important, clinical priorities or waiting time targets? They will rightly answer “clinical priorities”.

Now take the camera away, threaten them with loss of income or employment if they fail to treat their long-waiting patients, and turn a blind eye if clinical priorities are delayed. The consequences are as obvious as they are shameful. But delaying urgent patients to make room for long-waiters has happened before, and it may happen again.

Hidden waiting lists

Then there is the temptation to create “hidden” waiting lists, so that long-waiting patients don’t show up on the incomplete pathway figures.

This can be done blatantly (hiding referrals in drawers, creating “pending lists”, reclassifying patients as “planned”, or offering unreasonable appointments). Sometimes it happens through inattention (post-treatment follow-up backlogs). Sometimes it is the result of deliberate local policy (misusing low-effectiveness criteria to block or delay referrals).

 

So the new target, welcome though it is, leads us to new challenges and new dangers. They cannot be dealt with by national targets and national data collections; they must be tackled locally.

Good planning and management are clearly essential. But so is openness about local practices and policies; if patients and clinicians understand what is being done and why, you can be sure they will protest loudly and often if target-chasing ever dominates over basic fairness and clinical safety.