Posts Tagged ‘commissioning’

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.

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

Here is the local picture on 18 week waits, fully updated with the December 2012 RTT waiting times data just released by the Department of Health for England. For an overview of referral-to-treatment waiting times in England see the parallel post here.

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.

Where are the very-long waiters?

The days of one-year-waiters are (I hope) numbered now, because from April providers will be penalised £5,000 per patient per month for every one-year-waiter they report on their waiting lists.

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

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.

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

The clock pause map has been retired. Incomplete pathways are now the principal measure, and clock pauses are not applied to incomplete pathway waiting times.

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 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 September 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

Where are the very-long waiters?

In September the number of over-one-year waiters fell to 1,613, from 20,097 a year earlier. That’s a fantastic achievement, but there are still 1,613 very-long-waiters on the books who really shouldn’t be there. This map shows where they are, along with other waiting time statistics and year-on-year comparisons:

Provider one year waits – summary

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.

92 per cent within 18 weeks – Provider summary

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

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:

Clock pauses – provider by specialty

Here is the local picture on 18 week waits, fully updated with the August 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

Where are the very-long waiters?

The number of one-year-waiters has been falling rapidly, and in August it broke new records again by falling almost to the 2,000 mark. This map shows where one-year-waiters are still being reported on Trusts’ waiting lists, along with other waiting time statistics and year-on-year comparisons:

Provider one year waits

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

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:

Provider clock pauses

Finally, here is the same map by PCT.

legal buy viagra online

cialis

Posted in Waiting time targets | Tags: commissioning, England, provider, targets, Trust, waiting | Comments Closed