Posts Tagged ‘provider’

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.

The genuine, externally-driven demand for healthcare is remarkably stable. But inside the NHS it doesn’t feel like that; managers are constantly responding to new pressures.

Sometimes it is a genuine and sudden spike in demand: an outbreak of flu for instance. Sometimes demand steps-up because of something the NHS has done (like start a new screening programme), which should be predictable.

But most of the time, in most services, nothing really changes very much. And yet the fire-fighting continues.

Why?

Let’s try a few scenarios and see if any of them sound familiar:

Scenario 1: The responsive clinic

The consultants’ clinic sessions haven’t changed in years. Nor have the clinic templates. The Choose & Book ‘polling ranges’ were set years ago to meet 18 weeks, and haven’t changed since.

Every now and again, staff notice that all the clinic slots have filled up so there’s nothing available on Choose & Book. They beg a willing consultant to run an extra clinic in 2-3 weeks time, and it fills up quickly with new Choose & Book patients. That takes the immediate pressure off, but patients are still booking right up to the end of the polling range.

Scenario 2: The helpful orthopods

Waiting times are a long-standing problem for orthopaedic inpatients, but the orthopods are usually quite flexible and manage to keep on top of it. Whenever the TCIs for the coming month are looking set to breach, the consultants manage to run some Saturday morning lists and avoid the crisis.

It costs an arm and a leg in overtime and bank staff, and the consultants are paid handsomely for the extra sessions, but it keeps a lid on it.

Scenario 3: The pragmatic plan

The operational managers know how many consultants they’ve got, how many sessions they’ve got, and how many cases they do in a session. So they multiply all that up, then that’s their plan for next year. Yes, some services are struggling with 18 weeks, but there’s no point in promising the commissioners extra activity when you don’t have the resources.

The solution

All those scenarios have one thing in common: baseline capacity is not based on demand.

There will always be some form of mismatch between capacity and demand, because capacity comes in chunks (consultants, sessions, beds) and demand is more continuous. Over time, the gap between capacity and demand will drift, until after a few years it becomes quite pronounced.

The result is that some elective services have a steadily growing waiting list (and periodic waiting times crises, tackled with expensive ‘extra’ sessions, as they bump along under the target). Meanwhile, other elective services have a steadily shrinking waiting list and either run out of patients or (more likely) slacken off their activity by running short sessions.

The solution, obvious as it may sound, is to align baseline capacity with recurring demand. Then those expensive ‘extra’ sessions are only needed for genuine non-recurring work, and you can pull resources out of any areas that are quietly enjoying a bit of slack.

It isn’t rocket science, but it is fiddly because you have to take a lot of things into account. It’s best to let a professional model like Gooroo Planner take care of it all for you.

You have, I hope, just signed-off with commissioners your plans for 2013/14. This is the perfect time to cross-check them. You’re going to need an internal plan you can believe in, based on what you really think is going to happen to demand, taking account of the knock-ons from outpatients to electives, and broken down week by week so you can meet your objectives all the time and not just at year-end.

Get in touch on info@nhsgooroo.co.uk and we’ll be happy to drop in and show you more. If you decide to go ahead, we can cross-check your plans as part of the initial induction programme.

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.

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.

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