Many ways to breach 18 weeks

by Rob Findlay

The latest 18-week figures are out, and naturally the Department of Health is pleased that across the country 90% of patients were treated within the 18 week referral-to-treatment (RTT) target. But what about those hospitals who are struggling with 18 weeks? Are they simply overwhelmed? Managing badly? Or a bit of both?

Let’s start with the most extreme numbers of all, in Oral Surgery at the Royal Cornwall Hospitals NHS Trust:

Nearly half the patients are being treated in the last week before they breach the target. Panic? I would. Sustainable? Nope. Distorting clinical priorities? That’s a big accusation and I can’t demonstrate it on these numbers alone, but if I were at this hospital or its commissioner then I would be concerned.

In a normally-managed specialty you would expect to see some patients being treated quickly because they were clinically urgent, then fewer patients being treated in the middle, and then a peak on the right as the routine patients come in.

The number of urgent patients varies from specialty to specialty, which makes it more difficult to compare one specialty directly with another. So for the rest of this post we’ll stick to just one specialty, the one causing the biggest headaches on 18 weeks up and down the country: Orthopaedics.

Our first stop is the other side of the Tamar, at South Devon Healthcare NHS Foundation Trust. Here we find a very different picture:

Only 79% of their patients are being treated within 18 weeks, so on the face of it they are struggling. But otherwise things don’t look too bad. A good number of patients are getting in very quickly, and there are several possible explanations for this: either those patients have high clinical urgency, or one or more consultants have no waiting list and treat everybody right away, or lots of empty slots are being left in the appointments book and filled at short notice with routine patients. It isn’t possible to tell without more information, but I would hazard that this department could achieve 18 weeks without reducing the number of patients waiting or compromising clinical priorities.

Moving a lot further east now, let’s look in at Orthopaedics at Luton and Dunstable Hospital NHS Foundation Trust, where a very-similar 77% of patients are treated within 18 weeks:

The pressure is a bit higher here. A few patients are being treated urgently, then many patients are treated with middling waiting times, and then there’s a bit of a panic just before 18 weeks with some spilling over. The large number of patients coming in from the middle is a sign that different consultants have different waiting time pressures, or that patients are not being treated in order of priority and referral date, or both. Either way, the data suggests that this department could improve its 18-week performance by better scheduling alone.

So what does real pressure in Orthopaedics look like? Continuing our journey all the way to the coast, we come to Southend University Hospital NHS Foundation Trust, where again 78% of patients are treated within 18 weeks:

Very few get in urgently, then there’s a steady stream being treated in the middle, and finally a great surge in an effort to beat the target with quite a few spilling over. Could they achieve 18 weeks by managing their appointments better? Probably not. Are clinical priorities being distorted in order to achieve 18 weeks? It isn’t possible to reach that conclusion from this data, but if I were at Southend I would be looking closely at the management of clinical priority patients to ensure they are being treated quickly enough, and looking for ways to ease the pressure on the hardest-pressed consultants. Oh, and trying to reduce the size of the waiting list, of course.

Is this as pressured as it gets? Hardly. Let’s go west again to the lovely city of Bath. Similar to the other orthopaedics departments we’ve looked at, 81% of their patients are treated within 18 weeks. The profile looks like this:

RTT waits at Royal United Hospital Bath NHS Trust

At the Royal United Hospital Bath NHS Trust, almost none of the Orthopaedic patients are treated quickly. Very few come in from the middle of the list. Over 50% are treated in the last 4 weeks before the 18 week target. Here is a service under real pressure, where the only sensible answer is to reduce the number of patients on the waiting list. This is a totally different picture from Devon or Luton, although undoubtedly it feels like a struggle in all these hospitals.

Is that it? Not quite. To finish up, let’s go north to the University Hospital of North Staffordshire NHS Trust. It’s Orthopaedics again, but this time only 47% of patients are treated within 18 weeks. If I were to take a punt on this, I’d say they had given up on 18 weeks.

And to be honest, it’s hard to blame them.

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