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Posts Tagged ‘contract’

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.

What on earth is going on with the Government’s referral-to-treatment waiting times targets?

In the last few weeks we have heard great things from them, showing that they now understand the problems created by the current target regime and want to move forwards. For instance the new Operating Framework says:

The operational standards of 90 per cent for admitted and 95 per cent for non-admitted completed waits as set out in the NHS Constitution remain. In order to sustain the delivery of these standards, trusts will need to ensure that 92 per cent of patients on an incomplete pathway should have been waiting no more than 18 weeks. The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.

Operating Framework 2012/13, para 2.31

The new target is very welcome and in a perfect world it would have completely replaced the old targets (which punish Trusts for treating long-waiting patients). But abandoning the old targets would have required amendments to legislation, and invited political criticism that the Government was letting go of waiting times, so it isn’t entirely surprising that they have been retained.

This new, better direction of travel was reinforced in the latest edition of The Quarter. It said:

In addition to sustaining and improving performance against the NHS Constitution operational standards, the NHS must also ensure that those still waiting longer than 18 weeks are treated as quickly as possible. As set out in the NHS Operating Framework for 2012/13, from next year trusts will need to ensure that 92 percent of patients still waiting for treatment (also known as incomplete pathways) have been waiting no more than 18 weeks. Therefore, the NHS needs to take action to treat patients still waiting over 18 weeks after referral, for reasons other than choice or clinical exception.

In particular some trusts are currently reporting an unacceptable number of patients still waiting more than a year for treatment after referral.

At the end of September 2011, five trusts were responsible for around half of those people still waiting more than a year for treatment (see figure 12). These trusts, and any other trusts that are reporting patients still waiting more than a year for treatment after referral, must take action to understand the reasons behind these long waits and treat any patients still waiting as quickly as possible.

The Quarter: Quarter 2 2011/12, p.11

Amen to all that.

Which brings us to the latest big publication, which in many ways is the most important. The NHS Standard Contract lays out in detail the precise targets and penalties under which the NHS will operate in the coming financial year. Now that the Government has shown that it both understands the problems created by the old waiting time targets, and has shown willingness to change its approach in helpful ways, I would have expected the new Contract to:

1. pay lip service to the old treatment-based targets and the regulations underpinning them around the NHS Constitution, but
2. remove the financial penalties that actually punished Trusts for treating too many long-waiting patients, and
3. replace them with a new penalty regime that punished Trusts for having too many long-waiters on the waiting list, in line with the new target.

(I’m not saying that creating a new penalty regime is necessarily the best way of going about this, just that it would be in keeping with the traditions of NHS management.)

So what does the Contract actually say? Here are the relevant paragraphs in all their glory (my emphasis below):

Subject to Clause 43.6, if in any month the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 (Nationally Specified Events) for any specialty, then the Commissioners shall deduct for each such specialty an amount calculated in accordance with Section B Part 8.4 and weighted in accordance with Clause 43.5, from any payments to be made to the Provider under this Agreement.

2012/13 NHS Standard Contract, Section E, clause 43.4

Technical Guidance Reference: PHQ19-20

Nationally Specified Event: Percentage of patients seen within 18 weeks in respect of Consultant-led Services to which the 19 Weeks Referral-To-Treatment Standard applies

Threshold: For admitted 90% and over And For non-admitted 95% and over

Method of Measurement: Review of monthly report under Clause 39.1 of the Core Legal Clauses

Consequence per breach: As set out in Clause 43.4 of the Core Legal Clauses and Section B Part 8.4

 2012/13 NHS Standard Contract, Section B, Part 8.2 on p.16

Percentage by which the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 for each specialty (in respect of Consultant-led Services to which the 18 Weeks Referral-to-Treatment Standard applies) [heads a table column, with bands running from 0 to over 10 per cent]

Percentage of the revenue, derived from the provision of the (underachieved) specialty in the month of the underachievement, to be deducted under Clause 43.4 subject to the cap of 5% of the Contract Month Elective Care 18 Weeks Revenue pursuant to Clause 43.6 of the Core Legal Clauses [heads a column with penalties running from 0.5 to 5 per cent]

 2012/13 NHS Standard Contract, Section B, Part 8.4 on p.26

Lots about the old admitted and non-admitted targets, then. But where is the incomplete pathways target? Nowhere.

What will this do to waiting times? It fundamentally undermines the Government’s stated intention to reduce the number of patients “forgotten” on English waiting lists. For all the Government’s fine words, the new Contract retains the penalties that punish Trusts for treating lots of long-waiting patients, and creates no new incentives for them to achieve short waits on the waiting list.

When money is tight, and Trusts have a statutory duty to balance the books, which of fine exhortations and financial penalties is going to weigh more heavily on peoples’ minds? (That was a rhetorical question.)

Personally, I am baffled. Why did the Department of Health not carry the new target through from the Operating Framework to the Contract? I simply do not understand it.

So here’s a little suggestion to DH. While you are correcting the typo that refers to a 19-week target, why not take this opportunity to change the penalty regime over to “92 per cent of incomplete pathways within 18 weeks”? If everyone’s off over Christmas, I’ll even help with the drafting.

Have a lovely festive break.

[Update: The NHS Standard Contract, Section B, Part 8.2 was amended by DH a few hours after this post was first published at HSJ blogs. They fixed the 19 week typo, but not the target.]