Posts Tagged ‘targets’

The number of patients on the English waiting list increased sharply in March, according to the latest figures, and the total list size is now larger than in recent years.

There had been speculation that winter bed pressures, which caused cancellations of elective surgery in March and April, would lead to longer waiting lists. But the number of patients admitted from the waiting list was broadly on track in March, so the picture is not quite so neat and rising referral rates are part of the explanation.

The number of patients waiting is an early indicator of waiting times pressures to come, so a rising waiting list is cause for concern. But it takes time for the pressures to feed through. The position on 18 weeks was broadly stable in March with only a small deterioration, and the number of one-year-waiters broke new records as providers clear their extreme long-waiters before the zero-tolerance penalties begin in April. One-year-waiters fell to just 473 at the end of March, down from 665 the previous month and 5,149 the previous year.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

England-wide picture

The officially-reported number of patients waiting (i.e. incomplete pathways) rose sharply, and looks very high. But in recent years the NHS has been improving the coverage of its reporting, so…

If you strip out the effects of step-changes in the data then the list size looks more in line with the last few years. Nevertheless the increase in March has taken it to a new seasonal high which is cause for concern. (The adjustments used in the chart below take into account the return of North Bristol to this data series, which accounted for 27,185 of the increase.)

Admission rates continue to follow the broad pattern of previous years, despite the widely-reported winter pressures. Admissions per working day did fall slightly compared with February, when in previous years they have risen into March, but these figures do not show widespread cancellations on anything like the scale of the very cold winter of 2010.

One-year-waiters have again fallen rapidly, in advance of the zero-tolerance penalties for one-year-waiters which began in April. Other long-wait measures remain broadly steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, remains steady with just a small deterioration.

At specialty level, General Surgery finally tipped across the line to fail narrowly against the target. Orthopaedics continued to deteriorate, as did the more specialised long-wait specialties.

The proportion of services at provider-specialty level remained stable, with just a small decline from 85.2 to 85.1 per cent achieving the incomplete pathways target.

 

Provider top ten

Congratulations to the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) for nearly halving their one-year-waits backlog. They had to admit some 53 one-year-waiters to do this, which was the equal highest number of over-one-year admissions in England.

Trusts with the largest numbers of one-year-waiters remaining are: 79 at East Kent, 57 at King’s, 54 at RJAH, 42 at the Royal Orthopaedic, 39 at Barts, 16 at Doncaster, 16 at Royal Devon, and 13 at Southampton.

As mentioned above, North Bristol have finally restarted submitting waiting list data for the first time since July 2012. Bradford are still absent from this data series.

The April 2013 data is due out at 9:30am on Thursday 20th June 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick an NHS Trust or independent sector provider, or an NHS Commissioner, you can get a full analysis of the pressures in any specialty here.

Where are the very-long waiters?

The following maps compare one-year waits, 18-week waits, and total waits, with the values a year before. The first map shows providers, and the second shows commissioners and is therefore on a population basis.

The provider map shows NHS Trusts only to avoid map clashes with independent sector providers on the same site, but you can download the full data for all providers and specialties at the end of this post. In the map, click a pin to see the detail, then click the organisation  name to get a full analysis.

 

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 these maps shows how long 92 per cent of the waiting list has actually waited.

You can download a table of all the specialty-level detail here: Map-data.xls

February saw a further 21 per cent fall in the number of patients waiting over a year in England, hot on the heels of a 22 per cent fall in January. Across the country there were only 665 one-year-waiters at the end of February, down a massive 88 per cent from 5,653 a year earlier. For the first time ever, no provider had more than 100 one-year-waiters on its waiting list.

Providers are under pressure to treat their one-year-waiters because, starting with the end of April figures, they face ‘zero tolerance’ fines of £5,000 per patient per month if they report anyone still waiting more than 52 weeks after referral.

The position on 18 week waits was broadly stable, with 92 per cent of the list waiting up to 16.4 weeks and comfortably achieving the 18 week target at national level. The total size of waiting list, if you strip out step-changes, was broadly in line with the seasonal profile of previous years.

All figures come from NHS England, who have taken over responsibility for this data series. If you have a national statistic that you’d like to check up on, you can download our NHS waiting times fact checker

One more thing before we move on to the detail. You wait ages for a review of NHS waiting times and then two come along at once. These things really don’t happen very often (about once a decade) so if you have anything on your mind about how waiting times are measured then feel free to respond to the consultations by the National Audit Office and UK Statistics Authority.

England-wide picture

On the raw figures, the waiting list looks high for the time of year:

But if you strip step-changes out of the data (using the method explained here) then it doesn’t look out of line with previous years.

Admission rates continue to follow the pattern of previous years, despite the difficult winter.

One-year-waiters continue to fall rapidly, and we can expect even more dramatic reductions in the next couple of months as the zero-tolerance target comes in. Other long-wait measures remain steady.

My preferred measure of 18-week-waits, the 92nd centile waiting time for incomplete pathways, is holding steady.

Drilling down to specialty level, there is continued deterioration in orthopaedics and plastics, and in the more specialised services of neurosurgery and cardiothoracic surgery. General surgery has just scraped inside the 18 week target for another month.

The target must be met by every specialty in every provider in every month, and 85.2 per cent are succeeding, which is broadly stable from previous months.

Provider top ten

RJAH still has the longest ’92 per cent’ waiting times, and has the most one-year-waiters, but has gained some ground since the end of January. At number 2, Clinicenta have not improved their ’92 per cent’ waits, but they have cleared all their one-year waiters.

For the first time, no provider has more than 100 one-year-waiters on its waiting list. Those with the most are:  RJAH 98, Kings 73, Guys/St Thomas 44, East Kent 42, Royal Orthopaedic 35, Western Sussex 27, Brighton and Sussex 26, Southampton 26. Some 62 Trusts reported any one-year-waiters, down from 64 in January.

North Bristol and Bradford still aren’t submitting incomplete pathways data. North Bristol last submitted in July 2012, and Bradford in September 2012.

One provider dropped out of the top ten: congratulations to North Cumbria, whose improvement on ’92 per cent’ waits from 18.3 to 17.8 weeks has earned them a drop in the table from 10th to 34th place.

The 12-month statistics calendar has also moved to NHS England. The next figures (for the end of March 2013) are expected at 9:30am on Thursday 16 May 2013.

Here is the local picture on 18 week waits, fully updated with the latest RTT waiting times data just released by NHS England.

If you want to pick a Trust or independent sector provider, and get a full analysis of the pressures in any specialty, then all the detail is here. I’m afraid haven’t put the PCTs up this time because I had a software glitch overnight (and am hoping nobody will mind because they’ve all been abolished now anyway).

Where are the very-long waiters?

The following map compares one-year waits, 18-week waits, and total waits, with the values a year before. You can click the provider name to get a full analysis.

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.

Unfortunately the mapping service I use has limited their free service to 250 lines of data, so I can’t map the specialty-level data any more. But you can download a table of all the detail here: map data

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.

Just before Christmas the new ‘zero tolerance’ penalties for one-year waiters were announced. From April, any provider reporting one-year-waiters on their waiting lists will be fined £5,000 for each patient, every month.

That’s pretty hefty, and you might expect providers to respond by trying to clear their one-year-waiters before the penalties kick in. These latest figures are for January, so they come only a few weeks after the penalties were announced and perhaps it is early days. Yes, one-year-waits came down, but this was really just a continuation of the reductions that started back in the summer of 2011.

Meanwhile, the over-18-week waiting list is treading water with just a small (possibly seasonal) deterioration in January.

Underlying it all, the total size of the waiting list remains high for the time of year, and the gap over previous years is still growing. Some of the increase may be caused by providers improving their record-keeping as the waiting-list-based targets phase in, and I’ll be looking into this shortly to see if we can quantify that effect.

All the statistics used in this analysis are published by the Department of Health, and you can download a fact-checker with all the time series here: NHS waiting times fact checker

England-wide picture

The total number of patients on the waiting list is looking increasingly high for the time of year.

Admissions are still bang on trend.

The welcome reduction has continued in the number of patients waiting more than a year after referral. No sign, yet, of an acceleration before the zero-tolerance penalties kick in.

From April the main target will be that 92 per cent of patients on the waiting list must be within 18 weeks of referral. At national level this is still being met comfortably.

Dig a little deeper, to specialty level, and we see that long-wait specialties have been deteriorating since the start of winter. Among the big surgical specialties, Orthopaedics continues to drift away from target, and General Surgery is now flirting with failure.

The new main target from April, that 92 per cent of the waiting list must be within 18 weeks, must be met in every specialty in every provider in every month. At the end of January, 86.1 per cent of provider-specialties were succeeding and this (like the other 18-week indicators) has remained steady.

Provider top ten

RJAH tops the list again, and its reported long-wait position is even worse than in December (when 92% of the waiting list was within 36.5 weeks, and there were 97 one-year-waiters). Despite having the worst waiting lists in England, they still managed to achieve the current headline target by choosing 90.1 per cent of their admitted patients from the short-waiting end of their waiting list. This is a (very nice, and popular) specialist orthopaedics hospital and it is possible that their very-long-waiters are concentrated in one sub-specialty. (In orthopaedics it is, for instance, common to find particular pressure in spinal surgery.) Still, though.

In the number 2 slot, Clinicenta are reporting far fewer one-year-waiters (they had 26 at the end of December).

The Trusts with the largest numbers of one-year-waiters are RJAH with 119, King’s 118, Guys/StThomas 63, Nottingham 59, Newcastle 39, Royal Orthopaedic 38, West Sussex 38, and Brighton 35. Some 64 Trusts reported any one-year-waiters, which is a small improvement from 66 Trusts in December.

North Bristol and Bradford still aren’t submitting incomplete pathways data.

Congratulations to those providers who dropped out of the table since last month, with 92nd centile incomplete pathway waits falling from: 18.2 weeks to 17.5 weeks at Nuffield Health, Leeds Hospital; from 18.9 to 17.9 at Doncaster and Bassetlaw Hospitals NHS Foundation Trust; and from 18.0 to 17.2 at Southport and Ormskirk Hospital NHS Trust.

The 18-week statistics for February 2013 are due out at 9:30am on Thursday 18 April 2013.

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

One-year-waiters are continuing their steady improvement, and there are only 842 left. This should come down more rapidly now, in advance of the ‘zero tolerance’ penalty which starts in April.

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)

Some of the differences between Scottish and English waiting times are pretty obvious. England has three 18-week referral-to-treatment targets and a 6-week diagnostic wait (pp.38 & 58), whereas Scotland has one 18-week referral-to-treatment target, a 6-week diagnostic wait, a 12 week inpatient/daycase Treatment Time Guarantee, and a non-legally-binding 12 week outpatient wait (p.5). Already we can see that it’s quite complicated in England, but even more complicated in Scotland.

If you dig into these targets you find the rules are different too. The differences are pretty big, and many patients who would have a right to short waiting times in England, enjoy no such guarantees in Scotland.

For instance, if you are referred to an English hospital then they have to accept the referral and treat you (unless they don’t provide that kind of care, or you agree to be treated elsewhere) (pp.7-8). But in Scotland the hospital can routinely send its patients just about anywhere it likes (p.16), even if the destination is way outside the boundaries of its Health Board; any patient who refuses can be taken off the waiting list or have their ‘clock’ reset to zero (p.17). In case you think that such long-distance transfers might be a rare event, Scottish Health Boards have regular arrangements to send increasingly large numbers of waiting list patients to the Golden Jubilee National Hospital west of Glasgow, even from as far away as Orkney (p.5).

You have to be ready at short notice in Scotland too, because the NHS considers seven days’ notice to be a “reasonable offer” (p.15), compared with three weeks in England (pp.34-35). (To protect urgent patients, hospitals can offer shorter-notice appointments in both nations, and patients are free to accept or reject them without penalty.)

And you should avoid changing your appointment in Scotland, even if you give them plenty of notice, because the hospital can use that as an opportunity to reset your clock to zero; if you change your appointment three times, they are normally expected to send you back to your GP (p.19). There are no such sanctions for changing appointments in England even if you give only short notice (p.28). In both nations, though, you can be taken off the list and sent back to your GP if you fail to attend your first outpatient appointment without giving notice (i.e. you ‘DNA’) (p.20, p.28).

If you are ever unavailable for treatment, either for medical or social reasons, then in Scotland your ‘clock’ is paused (p.22-25). This rule was very heavily applied (pp.10, 19) until a recent clampdown. In England the new main target (based on incomplete pathways: p.58) does not allow clock pausing at all, although clock pauses were certainly allowed and used against the previous main target.

Then there are patients who are completely excluded from the targets. For obvious reasons, both England and Scotland exclude obstetrics from their waiting time guarantees. If you are waiting for an organ transplant, then the wait for the organ itself is excluded in both nations. And if you want to become pregnant then assisted reproduction is covered in England, but not in Scotland. (p.13-4)

Both nations have short-wait guarantees for cancer outpatient appointments and initial treatment, but the English guarantee covers all cancers (pp.38-40) while in Scotland there are exclusions covering several cancer types (pp.15, 25-26). If you are having a course of cancer treatment then, in England, you are guaranteed your subsequent treatment within time limits, whether it’s surgery, chemotherapy or radiotherapy (pp.39-40); but there are no such guarantees in Scotland (p.5).

There are different exclusions in diagnostics as well. Scotland applies the 6-week guarantee only to eight key diagnostic tests (p.14), which means that English (but not Scottish) patients are guaranteed a 6-week wait for DEXA and various kinds of physiological measurement (p.8). However in both nations the diagnostic wait is part of the 18-week referral to treatment wait, so this may not make a massive difference in practice.

Why are the English rules apparently so much more patient-friendly and inclusive than the Scottish ones? I think the answer was right at the start: the nature of the waiting times targets.

In England, the overall targets have a tolerance, for instance that 92 per cent of patients on the waiting list must be within 18 weeks. That leaves an 8 per cent margin for the odd exceptions (and there will always be exceptions).

In Scotland, though, the legally-binding 12 week Treatment Time Guarantee is a 100 per cent target. There will still always be exceptions, so they must be allowed for in the rules; which means you need lots of rules.

Personally, I think the English approach is the better one. (And in case anyone north of the border is starting to suspect a national bias, I should say that I am Scottish and was born and brought up in Scotland.) Hard cases make bad law, and trying to define all the reasonable exceptions in the rules is inevitably going to be complex and imperfect. Better simply to allow a tolerance in the target and let the rules include everybody.

Monitor is out to consultation on how it should judge NHS Foundation Trusts, and performance against the “18 weeks” targets is part of the mix. The deadline for responses is 4 April 2013, so this is a good opportunity to influence their proposed approach and fix its unintended consequences.

Monitor’s proposed approach

The place to go is page 78 of the consultation document. There are 28 targets and indicators, ranging from waiting times to C. Diff. to medication errors. Monitor propose that:

NHS foundation trusts failing to meet at least four of these requirements at any given time, or failing the same requirement for at least three quarters, will trigger a governance concern, potentially leading to investigation and enforcement action.

and each of the three 18-weeks measures is included as a separate indicator in the list:

• Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted: threshold 90%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted: threshold 95%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an
  incomplete pathway: threshold 92%

accompanied by the following note:

18 weeks referral to treatment: Performance is measured on an aggregate (rather than specialty) basis and NHS foundation trusts are required to meet the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure for the purposes of the Risk Assessment Framework. Failure in any month of a quarter following two quarters’ failure of the same
measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. Failure against any threshold will constitute a governance failure. The measures apply to acute patients whether in an acute or community setting. Where an NHS foundation trust with existing acute facilities acquires a community hospital, performance will be assessed on a combined basis.

Monitor will take account of breaches of the referral to treatment target in prior quarters (i.e. under the Compliance Framework) when considering consecutive failures of the referral to treatment target under the Risk Assessment Framework

Response

As usual with consultations, it isn’t always easy to tell which of the consultation questions is the right one for any particular issue. For this response, I’ve gone for Question 10:

Chapter 4 Question 10: Do you agree with the proposed approach to downgrading the governance rating – and ultimately finding a foundation trust in breach – as a result of either unresolved concerns for significant periods or concerns across multiple categories?

No (with regard to the “18 weeks” access targets)

Please provide more details:

Appendix A includes the three “18 weeks” access targets, and each target is considered independently when assessing the number and duration of failures. Unfortunately this approach has unintended and undesirable consequences.

Consider the following scenario : a Foundation Trust has developed a backlog of over-18-week waiters on its waiting list. Because of this backlog, it starts to breach the incomplete pathways target.

The most desirable cure for the backlog is to treat those long-waiting patients as soon as possible. Unfortunately, the current approach deters the FT from doing so.

The reason is that if the FT admitted all those over-18-week waiters, it would be likely to incur a second breach (against the admitted patients target). FT Board members have a strong incentive to avoid this further breach (especially if they are also breaching any other measures) by using a well-established tactic: taking care to admit only one long-waiter in every ten admissions. This severely restricts their ability to do the right thing and treat the backlog, and the proposed approach is therefore a perverse incentive. Put another way, for every long-waiter they admit, they must find nine short-waiters to admit out of turn; this is unfair to patients, and all that queue-jumping pushes up the longest waiting times.

So what should be done?

Ideally the admitted and non-admitted targets would be deleted. But I anticipate that this suggestion might not be acceptable, because both of those targets are currently specified in the NHS Standard Contract 2013/14 as well as the regulations underpinning the NHS Constitution.

So I would like to propose an alternative solution: that the three 18-weeks targets should be lumped together into a single-failure bundle. So a failure against any (or all) of them would only be one failure in total. Then, if an FT is breaching on incomplete pathways, it would not incur any further breaches by treating its long-waiters, so the perverse incentive is removed. The intended incentive (to avoid long-waiters building up in the first place, monitored across all three measures) is nevertheless preserved.

Scotland is getting results from its new legally-binding Treatment Time Guarantee (TTG), which guarantees that eligible inpatients and daycases will start treatment within 12 weeks of being added to the waiting list. The number of over-12-week-waiters on the list fell, for the first quarter in nearly 2 years, to levels not seen since December 2011.

However over-12-week waiters on the outpatient waiting list, which are subject only to a non-legally-binding target, continue to rise rapidly.

All data in this post comes from ISD Scotland, and I have excluded Lothian Health Board throughout (they would totally dominate the picture otherwise: they were caught with terrible long-waits but have been turning things around since).

If you do look up the original data tables you should be aware that the inpatient & daycase data is rather confusing at the moment. The TTG only applies to those patients added to the list after 1 October 2012 (and there are exclusions), so in the following chart I have added together the pre- and post-October data series in the hope of getting (reasonably) consistent data.