NHS gooroo blog

Posts Tagged ‘distorting’

Of all the referral-to-treatment (RTT) waiting times targets, the toughest is currently the “90 per cent” target. This requires 90 per cent of patients to have waited less than 18 weeks as they are admitted, on an adjusted basis. Adjusted, that is, for clock pauses.

I must confess, I had always assumed that clock pauses have only a minor effect. There might be one or two Trusts, I thought, where clock pauses were (shall we say) giving the adjusted admitted target a fair wind. So I was really quite taken aback when I looked at the evidence.

Clock pauses are only allowed in limited and defined circumstances. According to the RTT Rules Suite (p.22, my emphasis):

Clocks may only be paused for patient initiated delays at the admission for treatment stage of the waiting time pathway.

Once a decision to admit has been made, patients should, of course, be offered the earliest available dates to come in, as appropriate. However, where patients decline these offers, then, for a clock to be paused, they must be offered at least 2 reasonable dates for admission. Reasonable is defined as an offer of an appointment with at least 3 weeks notice.

Not much scope, you might think, for widespread pausing, or for provider-initiated pausing to help achieve the target. So how much are clock pauses actually used, and what effect do they have on adjusted admitted waiting times?

In the following chart, each point represents one specialty at one Trust, and it shows all Trust-specialties where at least 50 patients were admitted during June 2012. The position along the x-axis shows the 90th centile adjusted admitted RTT waiting time; i.e. the waiting time exceeded by only 10 per cent of patients, measured from referral to admission with clock pauses deducted. The position up the y-axis shows how much time was deducted for clock pauses, compared with the 90th centile unadjusted admitted RTT waiting time.

Do you think that an alien, looking at this chart, might be able to guess what the adjusted admitted target is?

You have to admire the accuracy with which so many services are achieving 18 weeks, with exactly the right amount of clock pausing.

It is also striking how much more common clock pauses are, in those services that are only just achieving the 18 week target. For services that lie between 17 and 18 weeks, some 42 per cent include at least one week of clock pauses; for the rest, the figure is just 24 per cent. Looking at it another way, the 17-18 weekers include an average 1.5 weeks of clock pauses, and the rest just 0.7 weeks.

Let’s drill down into one specialty in one Trust where the impact of clock pauses is especially clear. In the chart below, the unadjusted admissions are shown by the solid red columns, and the adjusted admissions by the solid red line (data from the Department of Health).

The gap between the line and the columns shows the net number of clock pauses: i.e. the number being paused minus the number coming off pause. There are no net pauses at all below 15 weeks, then 39 net pauses between 15 and 18 weeks, and then above 18 weeks they all start coming off pause again.

If this service had paused only 37 patients instead of 39, it would have failed the target. By a remarkable coincidence, it has achieved the target by a similarly narrow margin every single month for the last three years; the extent of clock pausing varies, but the adjusted result remains the same.

I am not making a blanket accusation that any service, that narrowly achieves the adjusted admitted target with just the right level of clock pauses, is misusing clock pauses in order to achieve the target. But I think it is fairly clear that some of them probably are, and some systematically.

Does it matter? Yes, but not as much as it used to, because the recently-introduced incomplete pathways target does not allow clock pauses to be deducted. If that target ever achieves the primacy it deserves over the adjusted admitted target, then pauses will become largely irrelevant. Normal levels of patient-initiated pauses (which, as we saw in the first chart, do not have a big impact on waiting times) will be absorbed within 18 weeks and the 8 per cent tolerance on incomplete pathways.

Even as the targets stand today, any service with a very high level of clock pauses will still breach the incomplete pathways target (as the example above does). Unless, of course, a service decides to adjust the incomplete pathways for pauses too. That isn’t allowed, but it does happen; how else could you explain the chart below, in which long-waiting patients are apparently being admitted even though there are no long-waiting patients on the list (and weren’t the month before, either)?

 

(The Department of Health has just published the checks they run across all the monthly RTT data submitted by Trusts, including checks on clock pauses. You can download the document “RTT Assurance Data Checks (PDF, 54K)” here.)

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.

Usually when Celtic nations borrow ideas from the English, they pick the best bits and leave the not-so-good stuff behind. Not this time. Scotland has just “achieved” its first 18-weeks referral-to-treatment (RTT) target, but this success is an illusion. Behind a distorting target, long-waits are shooting up at an astonishing rate.

As if that isn’t bad enough, the NHS in Scotland is also enduring a torrent of headlines about the Lothian waiting times scandal, with lurid tales of inappropriate offers, staff suspensions, fiddles, and bullying. Anyone outside Scotland, wanting to see from a safe distance just how nasty a waiting list scandal can get, should take a look (before checking out the antidote here).

How did it go so wrong?

Fundamentally, Scotland picked the wrong target. It copied the headline English target (that 90 per cent of completed patient journeys must be within 18 weeks RTT, adjusted for periods of patient unavailability). As in England, any Health Board can achieve the target simply by refusing to treat patients who have already passed the 18-week mark. And that, it seems, is exactly what has happened.

The Scottish Government wanted the 90 per cent target met by December 2011, and right on cue the NHS achieved 92 per cent. But they achieved it by suppressing the number of long-waiters being treated to a record low (figures from Table 1 here):

This would be fine, if it were genuinely the result of having fewer long-waiters still on the waiting list. But the opposite is true. We cannot make a direct comparison on a RTT basis because (unlike England) Scotland does not publish RTT figures about the waiting list itself. But there is data available for the separate outpatient and inpatient/daycase stages of the patient journey, and the official charts (reproduced below) could hardly show more starkly how the number of long-waiting patients still on the list is going up like a rocket.

It doesn’t look any prettier in raw numbers. Year on year, the number of patients still on the waiting list over 12 weeks went up from 1,769 to 6,141 for new outpatients, and from 210 to 2,019 for inpatients and daycases. The big numbers are concentrated in Lothian (as patients wrongly declared “unavailable” are returned to the waiting list), but there are sharp increases in other Health Boards too, showing that this is not a Lothian-specific phenomenon.

It is such a pity. These outpatient and inpatient/daycase targets, which apply to patients who are still on the waiting list, were meant to be the magic bullet that would stop backlogs building up, and stop the Scottish referral-to-treatment target from distorting waiting times as they did in England. But the backstop has failed. The distorting target won, it prevents Health Boards from treating enough long-waiters, and so the number of long-waiters still on the waiting list is going up.

Are there any plans to sort this out? The Scottish Government will take half a step in the right direction, with a 12 week legal guarantee covering some inpatients and daycases due to start in the autumn. But putting a small patch on a weakened backstop will not fix the underlying problem.

Instead, Scotland should look across the border and learn again from England’s mistakes. The new English target is the one to copy: that 92 per cent of patients still waiting must be below 18 weeks, on a referral-to-treatment basis and without adjustment for patient unavailability.

Even better, Scotland could do it first. Although English Health Ministers have accepted the logic of a waiting list based target, and gone to all the trouble of creating one, they have bizarrely delayed its full implementation until at least April 2013. Scottish Ministers could switch targets now, and rapidly achieve and sustain the genuine short-waits that they wanted in the first place.