Wider lessons from Imperial’s long waits

by Rob Findlay

Imperial College Healthcare NHS Trust is in the news, with startling reports of a breakdown in record-keeping that resulted in patients waiting up to 2-3 years. Some of the patients who got lost in the system were suspected cancer referrals who the Trust is still trying to locate, months or even years later. It has been a horrible, stomach-churning failure.

To their credit, Imperial seem to be sorting things out pretty quickly: fixing the data, validating the waiting list, following up patients they are concerned about, clarifying scheduling procedures, and strengthening planning, all with external assistance and oversight. I don’t have inside knowledge of the actions they are taking, but it does look from the outside as if they are doing what you would expect.

Looking more broadly, how could the NHS become more resilient against this kind of failure? How can we make sure it never happens again and, if it does, that it is caught much more quickly to limit the damage?

Ultimately the answer is for any kind of waiting list to be regarded culturally as a sign of failure by the NHS, and to make involuntary waiting a thing of the past. But well before we reach that happy state there are more immediate and practical things we should do:

The first step is to simplify dramatically the reporting and targeting of waiting times. In common with most Trusts, Imperial’s scorecard in November 2011 (the last before their reporting break) tracked no fewer than eleven measures relating to the 18 week targets. Only one of those measures related to long-waiters still on the waiting list, and it was the second from last item. What were the other ten? Eight related to other waiting times targets set by the Department of Health, and the remaining two were Trust measures that simply tracked the numbers of patients being treated.

This proliferation is completely unnecessary. Get the waiting list right, and all the other measures take care of themselves. The Department of Health accepts the logic of scrapping the admitted and non-admitted targets, so let’s just do it. Then Imperial and everyone else can boil their 18 week reporting down to a single measure: the 92nd centile waiting time for incomplete pathways, so that Boards can see right away when things are going pear-shaped.

The second is to put an end to one-year waits. Patients don’t know where they stand with a 90 per cent guarantee (they are left wondering: am I one of the 10 per cent?). But if they know that nobody waits longer than a year then something is definitely wrong if they have. A one year limit works for hospitals too: if no patient ever waits longer than a year then systems are unlikely to slip for more than a few months (at the outside) before someone notices.

Thirdly, we can improve the tracking and management of the most important patients on the waiting list: no, not the imminent 18-week breaches, I mean patients with a high clinical urgency. There is a data field in each PAS system for recording the urgency of every patient on the waiting list: two week wait, urgent, or routine;  but in many hospitals this field is poorly used. Using it consistently would strengthen waiting list management and reduce the risk of urgent patients being delayed.

Finally, and in the longer-term, we can increase resilience by strengthening patients’ expectations and involvement during their waits. To their credit, the Government have made a start on this with the Operating Framework requirement to publicise to patients the 18 week guarantee. But these generalities are not specific enough: even BT do better, with regular personalised text updates on the escalation and fixing of the fault on your line. If patients were kept closely in touch with progress on their appointments, then they would be better placed to catch the ball if it dropped. The usual system of fire-and-forget referrals, “you’ll get a letter” hand-offs, centralised complaints procedures, and all the rest is too distant and siloed and we can surely involve patients in a more predictable and personal service.

How pressing is all this? Around England, and particularly in London, there are plenty of hospitals reporting dozens (even hundreds) of patients still waiting more than a year after referral. How sure can we be that nothing similar is happening at any of them, or that none of those patients are waiting even longer than the 2-3 years found at Imperial?

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