Cut waiting times, breach the target

by Rob Findlay

Last week, the Board of Portsmouth Hospitals NHS Trust (PHT) considered the regular performance report from their Chief Operating Officer. The section on 18 week waits said:

Current Position: At the end of March there were 1,319 patients on the 18-week wait backlog.

Action: A plan was agreed with commissioning colleagues that PHT would focus capacity on clearing the backlog. This commenced in February and accounts for the deterioration in our performance against the 90% target for admitted patients.

That, in a nutshell, shows the dilemma caused by the government’s 18 week referral-to-treatment operating standards, as enshrined in the NHS Constitution and in law. It is clear from Portsmouth’s performance report that managers there understand the dilemma perfectly.

So what is this dilemma, exactly?

The government’s requirement for admitted patient waiting times is:

90 per cent of pathways where patients are admitted for hospital treatment should be completed within 18 weeks

…which sounds great, but is equivalent to saying:

Of every ten patients you select for admission,
only one is allowed to be a long-waiter.

Clearly, this becomes a serious problem when you have a lot of long-waiters.

To their credit, Portsmouth are tackling their long-wait backlog by actually treating their long-waiting patients, even though it makes them look bad against the headline target. In the circumstances, it would be understandable if they had chosen the alternative (as many other Trusts and commissioners do), which is to achieve the target by admitting mainly short-waiting patients, even though that allows the backlog to grow.

But it is somewhat harder to understand why the government continues to put Portsmouth, and dozens of other Trusts, in this dilemma at all. Alright, the 18 week rules were inherited from the previous administration, but waiting times are not exactly a low-profile issue, they’ve had a year to fix it, and the problem is only going to get worse as the backlog pressures grow.

Changing the rules would be straightforward: just apply the targets to those patients who are still waiting, instead of those patients who are lucky enough to be selected for treatment.

Ultimately this would mean changing the regulations that support the NHS Constitution. But the government could make a start more quickly by amending the Operating Framework, and only monitoring compliance against the 90th or 95th percentile waiting times for incomplete pathways (and ceasing monitoring against admitted and non-admitted pathways, or against the median).

That would greatly reduce the number of waiting time measures that Trusts need to monitor in their monthly performance reports, and help Trust directors focus on what is really important. And it would allow Portsmouth, along with all the other Trusts whose waiting time pressures are increasing, to concentrate on tackling the pressures properly without the risk of being penalised for their efforts.

(This post first appeared in HSJ blogs)
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