NHS gooroo blog

Posts Tagged ‘management’

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

Last month I highlighted the case of a Trust’s Orthopaedic patients, whose waiting time clocks seemed to be mysteriously stuck just below 18 weeks. It was not clear how this was happening, and now we are completely in the dark because they have stopped submitting data.

Then last week, while analysing the December release of 18-weeks data, I spotted a similar pattern at a different Trust. Here are the 2011 waiting list snapshots (i.e. the incomplete pathways data) for Orthopaedics at Salisbury NHS Foundation Trust.

Again, there is a peak in the number of patients waiting just below 18 weeks. Again, this peak does not move forward in time as each successive month goes by; you might expect the peak to move forward by one month, every month. And where do the patients in the peak come from? If these were patients just feeding through the list and then being treated in the usual way, you would see a plateau (where patients were not being treated) followed by a cliff (where they were), not a peak sticking up suddenly in the middle of the waiting list.

So it looks, on the face of it, as if patients in the peak are having their waiting times frozen somehow. According to the RTT waiting times rules, clock pauses are allowed under certain circumstances when measuring adjusted admitted pathways, but there is no provision for pauses in either the non-admitted or incomplete pathways data. So it is difficult to understand how a static peak, in the incomplete pathways data shown above, is possible under the rules.

Whatever Salisbury were doing in Orthopaedics in 2011, it was successful in narrowly achieving the headline target that 90 per cent of adjusted admitted patients should be within 18 weeks. When I say narrowly, I mean that in each of those 12 months their performance stayed in the range 17.962 weeks to 17.999 weeks (and was within two patients of failure on 7 of those months).

It is impossible to tell exactly what is going on, just by looking at these figures. If there is an innocent explanation then I would like to hear it. But if there isn’t, then I would hesitate to lay all the blame at the Trust’s door, because the target that is being so narrowly achieved is perverse. The system of harsh penalties and “performance management” surrounding it has the effect of coercing Trusts into doing bad things.

So if any changes in counting methods do turn out to be needed in Salisbury, it would be good to see commissioners and performance managers exercising restraint to allow the Trust to deal with any backlogs openly. Above all, it should not be forced into taking a ‘reporting break’. There are too many of those going on at the moment already.

As British schools broke up and everyone headed off for their summer holidays, the Co-operation and Competition Panel (CCP) published their final report on Any Willing Provider. One passage that caught journalists’ and commentators’  eyes was this (para. 91):

The imposition of minimum uniform waiting times at providers [by PCTs] also appears reasonably widespread.

The CCP reported that PCTs claimed two benefits of minimum waiting times.

• more equitable treatment for patients across different providers;
• reduced expenditure for taxpayers.

The CCP criticised the first as “an unfortunate levelling-down”, and the second as a “one-off benefit that cannot be repeated”. In response to the argument that longer waits can save money as patients remove themselves from the list, they said (in a much-reported footnote to page 29):

We understand that patients will “remove themselves from the waiting list” either by dying or by paying for their own treatment at private sector providers, and that there is a relationship between the self-pay market in private healthcare and the length of waiting lists in the NHS. However, research suggests that the effect of increasing waiting times at all hospitals is unlikely to be significant. A 10% reduction in waiting times is associated with an increase in demand of between 1.35% and 2.35%. Assuming increases and decreases in waiting times have a similar effect, it is likely that an increase in waiting times will have a small impact on overall demand for services.

Actually a 2 per cent fall in elective demand sounds like a very useful saving to pocket, in return for a small increase in waiting times from (say) 15 weeks to 16.5 weeks. Unfortunately the CCP do not provide a reference for their statement that “research suggests” this. There is other evidence that waiting times over 10 weeks may deter patients: RAND Europe, City University  and the King’s Fund surveyed patients’ attitudes to waiting times in 2006, and found (in para. 5.3.2):

For waiting times of 8 weeks or less, a change in waiting time is valued as zero. That is to say, on average there is no benefit from reducing the waiting time from referral to treatment below 8 weeks. Once the waiting time reaches 10 weeks, there is, however, a step change where the increases in waiting time are valued negatively (and significantly different from zero). It can be seen that the rate of change is relatively constant, implying that for waits of 10 weeks and above the valuation of waiting time increases approximately linearly.

In other words, patients are unfazed by waiting times under 10 weeks. But when waits are over 10 weeks, every extra week adds the same amount of extra disincentive. Whether this disincentive actually translates into reduced demand, unfortunately, is not something that RAND et al come to any clear conclusion about.

So what about the argument, advanced by the CCP and others, that it is pointless trying to save money by lengthening waiting times, because you only get the savings once? I think most commissioners would respond (as some did to the CCP) that once is better than never, and that if the requirement is 18 weeks then why divert scarce resources towards even-shorter waits for the least-sick patients in the system?

But I think minimum waiting times are objectionable for another reason: they create hopelessness.

Waiting times and waiting lists are not simply the balance of activity and the demand for healthcare. A fair amount of NHS activity is devoted to patients who are stuck in follow-up loops, who attend clinics when the result of their diagnostic test is not in the notes, who are referred to the wrong specialist, or who keep coming back as emergencies because their long term condition is not being managed.

If clinicians and managers can achieve system improvements that drive out this “failure demand” then waiting lists and times would largely disappear in those services. But no clinician or manager is going to bother, if all the benefits of system improvement are going to be instantly confiscated by a minimum waiting time requirement, bluntly imposed by the commissioner.

payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed

For this reason alone, minimum waiting times should not be an operational requirement; payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed.

Having said that, it is surely unrealistic to expect commissioners and trusts to plan activity based on (say) 10 week waits across the board, when their figures say that only 16 weeks is affordable? Or to continue to fund 8 week waits in General Surgery when Orthopaedics is struggling at 22 weeks?

To be sure, planning activity and capacity on the basis of 18 weeks, when the service concerned is currently achieving 10 weeks, is a step backwards. More than that, it is a shame, because those short waits were hard-won, and there is always the worry that letting patients wait is the easy way out for the NHS.

But times are tight. There is a difference between, on the one hand, commissioners using 18 weeks as their planning assumption, and on the other hand imposing 15-week minimum waiting times operationally on a patient by patient basis.

Good planning protects urgent patients

It is worth remembering that good planning, based on realistic assumptions about what is possible with waiting time management, also protects hard-pressed services by releasing resources for them. When long-wait targets are being aggressively pursued, this extra resource may be essential to stop urgent patients being delayed.

This post first appeared at HSJ blogs

PTLs have been around since the early 2000s as a tried-and-trusted way of achieving waiting time targets.

What are they? The name doesn’t tell you much (depending on who you ask, PTL stands for Patient/Primary Targeted/Targeting/Tracking/Treatment List) but the concept is easy enough to explain:

Pretend it’s the 1st of February. In 4 weeks time, on the 1st of March, you want to have no patients waiting longer than 18 weeks since referral. All the patients who could possibly breach that target have already waited over 14 weeks. You know who they are, and the “PTL” is the list of their names. If you book everybody on the PTL in for treatment during February, then (so long as you don’t cancel any) you are guaranteed to achieve the target. Simple.

But this deceptively simple approach creates problems of its own.

Firstly, if you have a serious waiting time problem, then it is very difficult to find slots for all those patients. You might end up using slots that should really be kept aside for urgent patients who haven’t arrived yet. If urgent patients end up being delayed as a result, then you have created a clinical risk that could result in patients being harmed. This is a serious matter which a good booking system should be designed to avoid.

Secondly, when booking the PTL, your main concern is to find slots in February. Exactly which patient goes into which slot may be considered less important. But if you book routine patients out of order then the maximum waiting time goes up: those lucky patients who squeeze in for treatment at 14 and 15 weeks are jumping the queue on those waiting longer, and we know that queue-jumping pushes up maximum waiting times. So at next week’s meeting you will have more difficulty clearing your PTL, even though your underlying waiting time pressures have not changed.

PTLs manage long-waits in batches and at the margins

These problems arise because you are managing your long-wait problem in batches and at the margins, and your actions have unintended consequences for the rest of the system. It would be better to manage the whole system continuously in the right way, and so achieve the best possible waiting times safely and consistently.

If this holistic approach means that you can achieve 12 weeks, then you will. (You might not have realised it was possible using PTLs.) If the best you can achieve is 20 weeks, then you have a problem; but your planning and monitoring systems should have picked up this pressure already and pointed to solutions for relieving it (perhaps by moving resources from those services that can achieve 12 weeks).

What if your waiting list is just too huge to achieve 18 weeks safely and continuously? Then your problem is not so much waiting list management, but a mismatch between supply and demand that needs to be tackled together with commissioners.

While you’re dealing with that, you need to ask yourself how you want to fail in the meantime. You are faced with three main choices:

1. carry on treating routine patients in turn even if they all wait over 18 weeks;
2. drip-feed your long-waits through the system so that at least you’re achieving the headline target (90% of admissions within 18 weeks) while the backlog gets worse; or
3. squeeze so hard that urgent patients end up being delayed.

The first is the high moral ground, and the holistic approach; the second is understandable; the third is surely indefensible. PTLs, unfortunately, are most likely to lead you towards the third.

This post first appeared at HSJ blogs

The “Liberative” Government’s health reforms started life with a light and permissive vision of GP commissioning. But now they are mired in confusion. What happened? In short, the new vision collided with the old. Last week the Health Select Committee sided firmly with the old vision, calling for Consortia to be renamed as Commissioning Authorities with formal governance structures and stakeholder representation.

New vision or old, everybody wants commissioning to be done well. But what does commissioning mean, and how should it change?

In the conventional vision, commissioning starts with the carefully-assessed healthcare needs of your local population. Then you compare this against the services actually provided. Inevitably, you find plenty of areas where needs are not being met at all, or where provision could be improved, or where there is over-provision and ineffectiveness. Starting with the biggest mismatches, you work with other stakeholders to design new and better pathways, and then you seek providers to deliver them (or work with existing providers to improve things).

Conventionally, you manage “your” providers through the annual contracting process. You estimate the amount of activity to be done, and then apply the tariff price (if there is one) or negotiate a price (if there isn’t). You manage quality using Key Performance Indicators (KPIs). If quality falls short or activity is at variance with the contract volumes, then you apply the remedies specified in the contract.

So far, so familiar. But this is all office-based activity. What are the chances of it making a real difference to patients?

You hope to reach a position where need and provision roughly match. But your experience shows that anything you measure in healthcare displays huge and unexplained variations; if you do find a match between need and provision, it is only by chance. And if you achieve a match today, then it probably won’t match tomorrow. So trying to match need with provision is going to be highly inexact at best.

0.5% of the population consumed over 20% of acute spend

Patients also show great variety even within a single pathway, and the sickest patients usually have multiple conditions. The harder you try to tailor a pathway to a particular condition, the more you find there are exceptions to the rule. Do these exceptions matter? Yes, because they are your most expensive patients. Data from one PCT shows that a mere 0.5 per cent of the catchment population (about 1,000 people) accounted for over 20 per cent of acute expenditure. So good judgement by GPs trumps good pathway specification when it comes to handling the sheer variety of patients presenting.

What about quality? You hope that quality and performance can be managed with KPIs and contractual sanctions. But “quality” is too rich a concept to be described in even the most comprehensive list of KPIs. The harder you try to specify everything, the more you lock yourself into the status quo. Moreover, anything that isn’t in the KPIs is simply driven out: the effort of monitoring everything else in the contract takes over. So quality needs to managed through dialogue, not specification, and the organised concerns of GPs are a better guide to quality than words in a contract.

Even activity – the crunchiest of numbers – is hard to control in the standard contract. You can try to limit elective activity if the waiting list isn’t rising. You can try to throttle cost by using activity caps and restrictions on “procedures of limited clinical effectiveness”. However, most contractual changes need to be implemented with the agreement of the provider (which may not be forthcoming), and in any case tactics such as banning procedures tend to be blunt and limited instruments that displace or defer the problem rather than solving it.

Finally, awarding contracts only to selected providers (especially if the contracts specify guaranteed volumes) involves saying “no” to other potential providers. The argument is that this helps to control expenditure, but again there is a lot of hoping going on: you hope that, by restricting the availability of providers, you will reduce demand. As Don Giovanni said in a different context:

Wer nur einer getreu ist,
Begeht ein Unrecht an den andern;

If I am faithful to one,
I am unfaithful to all the others;

Mozart

So the old vision of commissioning falls short on a number of counts. How could a new vision improve on it?

In commissioning, as with everything else in healthcare, real life happens in the consulting room not in the office. So better commissioning needs to happen in the consulting room too: if individual GPs manage their referrals and patient pathways well, then quality and budgets will follow. So the Consortium should focus its attention “downwards” to practices, rather than “upwards” to the Commissioning Board or “across” to providers.

That way, the life of a commissioner no longer revolves around the annual contracting round or the enforcement of KPIs. Instead, it revolves around helping GPs manage value, by:

• monitoring and escalating quality concerns raised by GPs;
• providing a “bank manager” function to GPs;
• peer-reviewing GP referral patterns and pooling risk;
• providing back-office, scheduling, and financial services to GPs;
• calling for new and better services, and helping prospective providers with their market research;
• ensuring that GPs are aware of the services and drugs available to them.

This moves decisively away from the adversarial contract-driven approach of the past. But one major step needs to be taken to make it work, a step that is not taken in the Health and Social Care Bill. Consortia need to be able to enforce budgetary limits at practice level, which is something that politicians (understandably) have tended to shy away from.

However, there is nothing to prevent GPs from opting to accept practice-level budgetary limits within their Consortium, or even formalising this rule in their Consortium’s constitution. After all, many GPs are pretty fed up with having their referrals interfered with, and their choice of providers restricted from on high, whenever PCTs are struggling to achieve their statutory duties because they cannot control demand.

So GPs and their Consortia are faced with a choice: genuine freedom to refer within a limited budget that they control; or a continuation of the imposed and inconsistent restrictions that face them now. What will they do? Perhaps the best outcome would be for different Consortia to make different choices. That would truly test the two visions of commissioning.

Most Trusts are achieving the 18 week operating standard. But some aren’t, and others are slipping towards failure. What should they do about it? Throw scarce money at it by creating extra capacity? Or can the problem be fixed more cheaply by managing better? And how can they tell which is the right approach?

We are currently writing to English Trusts, indicating their Trust’s likely best approach in all main surgical specialties. This post puts those individual reports into context, showing the national picture and explaining in more detail how the reports were constructed.

Here is a chart showing General Surgery at English hospital Trusts. (The format was introduced in a previous post.)

Three Trusts have been picked out in different colours. Here is the distribution of referral-to-treatment (RTT) waiting times for the red Trust:

The waiting time report being sent to this Trust says (for General Surgery):

• Achieving 90% within 18 weeks? No – only achieving 70%
• Clinical priorities under pressure? Indication of some pressure to delay urgent patients (proportion admitted within 4 weeks RTT is in lowest quartile)
• Scope to reduce waiting times by better scheduling? Possible scope for significant improvements at modest cost by improving scheduling

Looking at the charts, we can see where these statements come from.

• On the bubble chart, the red bubble lies well to the right of the “90% within 18 weeks” line, and is out at 30% breaches (i.e. 70% within 18 weeks), showing that the 18 week operating standard is not being met.
• Looking at the vertical position of the red bubble, we can see the proportion of patients treated within 4 weeks RTT: this Trust lies between the bottom line (lowest decile) and second-bottom line (lowest quartile), so the Trust’s report states that there is an indication that clinical priorities might be under pressure, because the proportion treated quickly is in the lowest quartile.
• Looking at the red column chart, we can see that a significant proportion of patients are admitted with intermediate waiting times from 4 to 15 weeks. Because these cohorts form a majority of the non-urgent patients, the Trust’s report states that waiting times might be reduced by improving scheduling. This statement is only suggestive, because there may be good reason (such as subspecialisation between consultants preventing waiting time pressures from being shared across the specialty) why better scheduling might have limited impact.

For the Trust picked out in amber, their waiting time report says:

• Achieving 90% within 18 weeks? Only just – 92%
• Clinical priorities under pressure? No indication of pressure to delay urgent patients
• Scope to reduce waiting times by better scheduling? Likely scope for major improvements at modest cost by improving scheduling

because

• The amber bubble is only just to the left of the 90% line.
• The bubble is above the lowest quartile (second-from-bottom line), so there is no indication (based on the proportion treated within 4 weeks RTT) that clinical priorities are being squeezed.
• Lots of patients are being treated with intermediate waiting times – neither as urgents nor as 18-week pressures.

And here is the green Trust:

This Trust’s report says:

• Achieving 90% within 18 weeks? Yes – 97%
• Clinical priorities under pressure? No indication of pressure to delay urgent patients
• Scope to reduce waiting times by better scheduling? Possible scope for significant improvements at modest cost by improving scheduling

It so happens that all three examples have indicated scope to reduce waiting times by better scheduling, but this is not always the case. In General Surgery we indicate “likely” scope for 45% of Trusts, “possible” scope for 25% of Trusts, and “limited scope” for the remaining 30% of Trusts.

Finally, here are the bubble charts for the other main surgical specialties.

Hospitals accepting unselected medical emergencies must have on-site surgery.

Acute health care services: Report of a Working Party.
Academy of Medical Royal Colleges, September 2007, p.22

There’s a lot of guidance like this, from the Royal Colleges, subspecialist societies, NCEPOD, and the Department of Health, all describing in helpful detail the critical links that exist between different acute services.

But each document describes only a few strands in a complex web of interdependencies. Senior clinicians and managers, however, need a system-wide view, but it is difficult to piece together the whole picture from this mass of detail.

The lack of a big picture can waste a lot of time. When acute reconfigurations are being considered, managers and clinicians may get together in a large group to draw up the reconfiguration options. Much later, after a lot of work, some options have to be struck out when a fatal flaw is discovered (such as not being able to separate paediatrics from obstetrics). At worst the lack of a big picture can be dangerous, when piecemeal changes are made locally, to individual services, without realising that they could destabilise the whole hospital.

So we need an overview of these important clinical linkages. Looking only at those 24-hour services that must be provided on the same hospital site, we think the links look something like this. A solid line means that one service must support the service it points to; a dotted line means that it is possible to run the service without that support but procedures must be in place to ensure safety.

There are caveats of course. It isn’t possible to capture all the nuances of this complex guidance in one diagram: for instance, the distinction between a selected and unselected acute medical take is not fully captured. Also there are cases where older guidance states a requirement that is not mentioned in more recent, overlapping guidance; this leaves it unclear whether the requirement has been softened. In the full version of this work, therefore, the diagram is accompanied by the relevant passages from the guidance (referenced by the numbers beside the arrows).

We think this is the first time that acute clinical linkages have been comprehensively published in this way. At a time when acute hospitals and commissioners are under pressure from the EWTD and the financial squeeze, many are considering whether they could transfer services to an adjacent hospital or stop providing them altogether. This map of acute interdependencies should help to show where this can, and cannot, be done safely.

To take just one example, could you save money by downgrading physiotherapy to daytime only? A novice manager might think so. But the answer is clearly no, because that would put at risk the intensive care unit, acute surgery and medicine, and the A&E department. Not a career-enhancing move.

A new video shows the power of better patient scheduling to reduce waiting times. It shows waits falling from 20 weeks to 14, just by managing bookings better.

What made the difference?

• the right number of slots was reserved for urgent patients
• urgent patients waited as long as was clinically safe for them
• only genuinely urgent patients were declared urgent

The video tells the story by itself. So let’s look instead at something the video doesn’t cover…

Follow-up outpatients

Imagine this: You are booking referrals into outpatient slots. Every routine patient gets the next available slot. You’re busy, and all slots are fully booked up for the next few weeks. Then an urgent referral arrives, and the patient needs to be seen quickly. But all the early slots are full. The only way to squeeze them in is to cancel someone else. But who?

In the video we assumed that a routine first appointment would be cancelled – whoever is least inconvenienced by the delay. But many hospitals prefer to cancel follow-up patients instead (usually two or three, in fact, because follow-up appointments tend to be shorter than new appointments). This lets them make space for the urgent patient, without putting extra pressure on their 18-week waiting time target by delaying a first appointment.

So which is better? If you have to cancel patients, should you cancel one routine first appointment, or two (or three) follow-ups?

To answer this, we need to look at follow-ups more closely. A follow-up patient should (if referred appropriately) be someone who needs to be seen during a specified window of time: for instance 2-4 weeks, or 5-8 months, after their previous appointment.

The first thing to point out is that some patients are followed-up unnecessarily, so the first priority should be to ensure that patients are only followed-up for the right reasons. Clogging up the clinic with unnecessary follow-ups is a waste of clinicians’ time, and the patients’.

Now let’s look at this time window. If the patient could just as well be followed-up after 8 months as 5, then it makes sense to go for 8 months. Why? Because it reduces the number of follow-up appointments in any given year, releasing capacity for other work. Otherwise you end up seeing patients more often than necessary, which again wastes everybody’s time.

But there is a consequence. Once the patient reaches the 8 month mark, they really do need to be followed-up now. In effect, they are clinically urgent. So we can’t cancel them. We should cancel a routine first appointment instead, if we have to.

So the story told by the simulation video is the right one. We should cancel routine first appointments, not follow-ups, if we need to make space for urgent referrals. As the simulation shows, it is possible to do this and keep waiting times to a minimum.

“Cancellations push up waiting times. So does a big waiting list. Common sense, isn’t it? You don’t need a model to tell you that.”

All true. But what common sense doesn’t tell you is how much they push up waiting times. This matters when you’re looking at a 10-week outpatient wait and trying to get it down to 8 weeks – you need to know how big an effort you’re going to need.

So what does increase waiting times? And is there anything you can do about it? If you can answer those questions, then you’re well on the way to cutting waits at almost no cost, and without wasting valuable time trying to fix things that don’t actually matter.

This post reports on simulation research by Gooroo that investigates the (sometimes surprising) effects of different kinds of disruption on waiting times. (It does not consider the effects of good and bad practice when booking patients; that will be left for a later post.)

Things that make a big difference

Urgency of casemix

Urgent patients, by definition, need to jump the queue because of their clinical conditions. And the more queue-jumping there is, the longer other patients wait, and the longer the longest waiting times.

Similarly, just how quickly these “urgent” patients need to come in also makes a significant difference to waiting times. The quicker they come in, the more other patients are pushed back, and the more the longest waits go up.

All this is well-established, and the routine waiting time you would expect as a result can easily be calculated.

But something else happens as well. Urgent patients also cause a lot of general disruption when booking patients. The more urgent patients there are, the more disruption there is. Both the number of longwaits (after taking into account the queue-jumping effect), and other undesirable events (like delayed urgent patients and rebooked routine patients), increase steadily as the urgency of the casemix goes up.

You can’t alter the clinical urgency of the patient. But you can increase the care taken to describe their clinical urgency accurately. If urgency is being systematically over-declared, then waiting times are being needlessly increased. So it is worth paying close attention to the process and criteria used to declare the urgency of patients.

Number of patients waiting

If a list gets bigger (relative to activity) then waiting times go up. Again this is well-known, easily quantified, and the expected routine waiting time can be calculated with the size of the waiting list taken into account.

But again, there are additional effects. Bigger lists suffer much more disruption than smaller ones. Again the disruption increases the number of longwaits who exceed the expected routine waiting time, though it does not greatly affect urgent patients or rebookings.

Controlling the size of the waiting list is already a priority throughout the NHS, so this finding merely adds emphasis.

Removals

Here “removals” means those patients who are removed from the waiting list well before they come in for their appointments. If a patient already has an appointment booked, then this is cancelled and reused for another patient.

You might expect removals to cause some disruption, but not much. But that expectation does not account for the sheer numbers of patients removed from NHS waiting lists. For admitted patients (inpatients and daycases) it is quite typical for 15% of patients to be removed, and often as many as 25%. At such high volumes of removals, the level of disruption is huge, with longwaits and rebookings being the main consequence.

So any action that might reduce the number of removals, by ensuring that patients are only added to the waiting list if they are likely to proceed with their appointments, would be beneficial.

(Suspending patients is not currently practised in England, but is used elsewhere, and this practice has a smaller effect on longwaits and rebookings.)

Modest effects, but still worth looking at

The following effects would be worth looking at too, but more for reasons other than reducing disruption.

If patients are cancelled on the day of their appointment and subsequently rebooked, this causes a moderate increase in disruption, in addition to the waste of capacity caused by their unused appointment slot. (Patients who are cancelled but not rebooked, like many Did Not Attend (DNA) patients, waste capacity but do not cause disruption.) If the main motivation for tackling cancellations is to reduce wasted capacity, then deliberately over-booking every session (and accommodating the resulting variability in session length) would be worth considering as a compensating tactic.

If significant numbers of patients are pooled between several clinicians, this helps to even out waiting times (and therefore reduce the maximum waiting time for the service). This levelling of waiting times should be the main motivation for this tactic. As a useful side-effect, it also happens to reduce the amount of general disruption and so produces a further benefit on waiting times.

Likewise if sessions are combined (e.g. running one all-day operating list, instead of two half-day lists a few days apart) then there is a small benefit for longwaits and rebookings. This benefit is partially offset because there is a slight increase in the delay to cancelled urgent patients as a result of the less-frequent sessions. Again, combining sessions would normally be considered because of other motivations, namely making it easier to schedule long procedures flexibly, which is why all-day sessions are beneficial in specialties like orthopaedics that have common, long procedures.

For full details of our research into the causes and effects of disruption, see Research White Paper 3. For quantification of their effects on waiting times, see Research White Paper 5, or use Gooroo’s Booking Rules Calculator for individual services (this appears just after login) or Gooroo Planner for bulk analysis.