Time for a one year maximum wait?

by Rob Findlay

Remember when London was awarded the Olympics? There was a real sense of achievement and national pride; it was almost contagious. People in the NHS felt a bit like that 20 years ago, when waiting times of 2 years and more were consigned to history.

But how would we feel if the International Olympic Committee changed its mind, and the Olympics never came? Imagine how let down we would feel as a nation. Nobody likes a broken promise. So how do 20,000 of our patients feel today, when the NHS from top to bottom promised them an 18 week wait when they were referred, and they are still waiting for treatment a year later?

In fact the NHS has never achieved a maximum wait of 12 months on a referral-to-treatment (RTT) basis. Six NHS Trusts now have more than 1,000 people whose treatment has been delayed by a year or more. And it’s actually us managers and clinicians who are responsible for meeting those patients’ expectations. So each of us needs to look in the mirror when searching for an explanation. Whether you shave or wear lipstick that could make for an uncomfortable start to the day for many of us.

What could we do about it? Eliminating excessive waiting times is difficult: it took the NHS over 4 decades to clear its 2 year inpatient waits, and it only happened when a forerunner of the NHS Constitution (the 1991 Patient’s Charter) made this a top priority. Some 42,000 two-year waiters were cleared in just 80 working days – perhaps helping to get John Major’s Government re-elected (somewhat unexpectedly) a week or so later.

How did the NHS achieve such an historic step change? Three factors were central:

1. Production engineering: 42,000 ultra-long-waiters sounded an awful lot, until you realised two things: firstly, it was less than 6 days’ acute work; and secondly, patients were being treated in nothing like the order that clinical priorities (or a basic sense of fairness) would require.

2. Leadership: everyone from the NHS Chief Executive down committed themselves to getting the result. No excuses. No exceptions. Individuals were held accountable for their share of the outcome required – and were offered additional support where it was needed in particular ‘hot spots’. Success was celebrated – the Task Force set up to focus everyone’s energies even gave out highly-publicized ‘golden scalpels’ to recognize some real heroes.

3. Shared values: in particular, Personal Treatment Plans were introduced to remind everyone that the NHS doesn’t treat statistics. You can’t clear long-waiters unless you literally know the names and needs of every last one of them. All the millions of patients treated quickly can’t excuse the terrible consequences for the forgotten few, who wait quietly to be discovered as you validate out the data errors from your list. You’ll find some real examples at HSJ blogs (“When the long-waiters are forgotten”), including an infant listed for an operation because of a haemangiona (malformation of the blood vessels) on her wrist, who was still waiting in her teens; and a man whose operation but was cancelled because of “no theatre time” and was found, still waiting to be offered another date, after 15 years on the list.

This relentless focus: fairness, getting operations for people, and keeping promises, meant that clinicians and everyone else were pleased to do their bit.

We believe that if these principles were applied again today, the NHS could again achieve something that changes forever the way people think about their health service: to achieve, once and for all, a guaranteed one-year maximum wait from referral to treatment in England.

In a parallel blog post today we show that it can be done. One-year pressures are highly concentrated in just a few Trusts and specialties (and no, orthopaedics is not the biggest problem).

When patient scheduling is improved and the smaller pockets of one-year waiters have been tackled, our analysis shows there are only 11 services in England (at Trust-specialty level) facing truly stubborn pressures. They have one-year clearance times over 10 days and sustainable maximum waiting times over 1 year. Because so few services are in this position, we expect the problems could be eased by working with Trusts and Commissioners to dissipate the pressure locally. With sufficient will, we think the job could be done in about six months.

We can be pretty sure the IoC will keep its promise, and the Olympics will come to London in July as promised. Wouldn’t it be great if the NHS could achieve a ‘personal best’ of its own – by removing the stain of one-year waits before the athletes arrive?


About the authors: Anthony McKeever was head of the government’s waiting times task force in 1992, has been Chief Executive of several Trusts and Commissioners. Rob Findlay is founder of Gooroo Ltd and a longstanding specialist in planning, scheduling and waiting times.
This post was first published in the Health Service Journal on 17 November 2011


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