Lessons from Scotland

by Rob Findlay

The Scots usually take a pragmatic attitude to English policy initiatives: wait and see if it works, and if it does then copy it. So I have to admit that I groaned when I saw Scotland’s new waiting time targets. Failing to learn from English mistakes is perhaps excusable, but why make them even worse?

What has Scotland done? They introduced a referral-to-treatment (RTT) target that 90 per cent of patients will wait no longer than 18 weeks from GP referral to treatment, to be achieved by December. So far, so familiar. The problem? They are monitoring their progress by watching only the waiting times of those patients lucky enough to be admitted. Unlike England, they are not also monitoring the RTT waiting times of patients who are still waiting.

In England, we know from experience that hospitals can meet this target simply by ensuring that, of every ten patients treated, only one is a long-waiter. That is how some English Trusts manage to “achieve” the headline 18-week target, even if they have massive waiting lists with patients waiting over a year.

At least in England those patients who are still waiting (the “incomplete pathways”) are still monitored, so that this kind of behaviour can be picked up. In Scotland they aren’t even looking. So is all lost in Scotland?

Not quite. The Scots have some older targets up their sleeve: maximum waiting times for each stage along the pathway. A maximum 12 week wait for outpatients, 9 weeks for inpatients and daycases, no exceptions.

How does this matter? 12 + 9 = 21 weeks, which is longer than the new 18 week target. Aren’t these targets redundant? No, because these waiting times are monitored for patients still waiting (as well as those seen or admitted). So if any Trust tried to “game” the 18-week RTT targets by titrating their long-waiters, they would run into the stage-of-treatment targets a few short weeks later.

There are some potential loopholes still. Trusts could conceivably abuse the targets by holding patients in follow-up loops or excessive diagnostic waiting lists, and then titrating them through the 18 week target. It would have been better in Scotland to monitor the 18-week target in terms of patients still waiting, instead of those admitted.

But perhaps Scotland has achieved something that England could learn from? If English politics rule out a change in the 18-week target, then perhaps a Scottish-style backstop could be introduced? The 6-week diagnostic target sets the precedent for stage-of-treatment targets based on a census of patients still waiting. Could we have a backstop for other stages too?

This post first appeared at HSJ blogs
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