Austerity and waiting times (1)

by Rob Findlay

Austerity, cuts, efficiency savings… whatever you call them, they’re coming. Life is going to be tough. Keep your head down, and you might just make it through.

Is that really the best approach, though?

When an age of austerity is galloping over the horizon, you want to be ready for it. What is austerity going to do in your part of the NHS? How can you make sure that if things start to fail under pressure, they “fail safe”?

In this two-part posting we will look at the effects of austerity on waiting times, and outline a response to it both from the hospital’s point of view and from the commissioner’s. Let’s take the hospital’s perspective first.

Waiting times – the hospital’s view

In an age of austerity, are GPs going to refer fewer patients? Perhaps they should, if commissioners can’t afford to pay for the extra activity. But past experience is not encouraging: referrals tend to rise year on year, regardless of the ability of commissioners to pay, and indeed commissioners have no powers to prevent it. So we need to be prepared for referrals to continue rising.

What about activity, will that carry on rising too? It might, modestly. But when it comes to waiting times, the absolute level of activity doesn’t matter: the question is whether activity can keep up with demand or not. In a time of austerity, we must assume not.

If activity falls behind demand, then waiting lists get longer. What then? Is it inevitable that waiting times will increase? If the shortfall is at all significant, then yes.

So are we all doomed? Will demand outstrip activity, waiting lists and waiting times go up, waiting time targets be breached, and everybody get the sack?

Not necessarily. That simple tale of woe conceals a lot of assumptions, and once we unpick those assumptions we can start to find a way through.

Let’s start with waiting lists and waiting times. Yes, if our waiting list goes up significantly then the average waiting time will go up too. But our target has nothing to do with average waiting times, it’s about the longer-waiting patients on the list, and long waits are affected by the way we schedule patients as well as the number waiting.

So step one is to make sure we are scheduling patients in the best way, so that long waits are minimised for the size of waiting list we have. In most cases this should provide quite a lot of headroom for our waiting list to grow, without breaching our waiting time targets.

The next thing we need to do is make sure other parts of our hospital are scheduling correctly too. Why? Because if we don’t, then other services might develop waiting time problems that should be solved by better scheduling, blame them instead on the size of the waiting list, and then consume scarce resources by laying on a waiting list intiative. Those resources might have been better spent elsewhere, perhaps on our own service, and we need to prevent this waste from happening.

What if we have done all that, and are scheduling correctly, but we still develop a waiting time problem? Now the problem must be the size of the waiting list, and there are several things we can try:

  1. look for ways of “pooling” work between different parts of our service – if we are about to book a patient into an appointment slot where they will breach the waiting time target, see if an earlier slot is available with a suitable alternative clinician?
  2. check that our data about the list is “clean”: e.g. no duplicates, no appointments still booked after the patient was removed, no follow-ups booked as first appointments;
  3. look for cost-neutral ways to increase activity: e.g. reduce follow-up appointments to free up capacity, ensure patients see the right consultant first time;
  4. look for ways to reduce demand: e.g. helping GPs to manage patients in primary care settings, working with GPs to reduce inappropriate referrals;
  5. finally, seek extra resources to lay on extra activity.

If we do end up seeking extra resources, then we will have to make our case well. We need to show that our scheduling is good, either by demonstrating that we are following the right booking processes or by showing that the shape of our waiting list is appropriate to our casemix. We also need to show that we have exhausted possibilities 1-4 in the list above. Ideally, we should also show that some other service in our hospital has slack that we could take advantage of, in the form of poor scheduling or poorly-used capacity.

What if we have done all of these things, but we still have a waiting time problem? What’s the worst that can happen: a breach of our waiting time targets?

Actually, there is something worse than breaching the target when our waiting list is too big, and that is not breaching it. That would mean we were prioritising long-waiting routine patients at the expense of urgent patients, with the result that urgent patients waited too long and were put at clinical risk. Unfortunately this does happen in real life, especially when managers cannot distinguish between services that have genuine pressures and those that could solve their own problems.

Our understanding of waiting times and scheduling is now advanced enough that there should be no excuse for this any more. Resources should not be thrown at services whose problem is poor scheduling, nor withheld because of a misperception that the pressures are not genuine. This is the same issue that commissioners face, and in the second part of this post we will look at the problem from their perspective.

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