“18-weeks” penalties change again: this time it’s good

by Rob Findlay

In a very welcome last-minute change, the Commissioning Board has just amended the ‘final’ NHS Standard Contract 2013/14 and given top priority to clearing the long-wait backlogs on England’s NHS waiting lists.

There has been a dramatic turnaround in waiting times penalties during the drafting of this Contract. The ‘near final’ draft, published just before Christmas, perversely penalised hospitals for treating long-waiters, but not for allowing long-wait backlogs to build up in the first place (though it did introduce the new backstop penalties for having one-year waiters on the list). The supposedly-final version of the Contract, published on Monday, added new penalties for building up long-wait backlogs but gave them little weight. Today’s version of the Contract correctly slaps the highest penalties on the backlog, and reduces the legacy penalties for treating long-waiters.

As the final Contract stands now (Particulars p.58), any hospital specialty that allows more than 8 per cent of the waiting list (incomplete pathways) to exceed 18 weeks will be subject to a sliding scale of penalties up to 2.5 per cent of elective revenue. The older targets linger on, so that if they try to clear their backlog, and more than 10 per cent of the patients they select for admission have waited over 18 weeks, they face penalties up to 1.875 per cent of revenue. That is perverse, but it isn’t as bad as it sounds. Because the penalties are applied monthly, it is much cheaper to clear the backlog and pay the smaller penalty temporarily, than to let the backlog fester and pay the higher penalty indefinitely.

This fundamentally changes the incentives around waiting times, putting the emphasis firmly on avoiding backlogs rather than managing them. Nevertheless providers need to be aware that it is perfectly possible to achieve the ’92 per cent incomplete pathways’ target every month, and still consistently breach the ’90 per cent admitted patients’ target. When planning the list size that is consistent with sustaining all the 18-weeks targets (as sensible specialties do) it it best to plan against the most demanding one.

All this has felt like a very long journey. Waiting-list-based targets were first announced by Andrew Lansley as long ago as 17th November 2011, but disappointingly weren’t written into the subsequent NHS Standard Contract. Although the Mandate mentioned the waiting-list-based target as well as the treated-patient-based ones, it wasn’t clear about their relative priorities (and the waiting-list-based target was at a disadvantage because it wasn’t enacted in legislation until last week). But now it’s done, and the waiting-list-based targets have finally reached the top of the pile.

Why did it take so long? The main justification is that the incomplete pathways (waiting list) data is much more error-prone than the treated-patients data. When the last Labour Government introduced referral-to-treatment waiting times targets, it was a massive technical challenge to stitch together the waiting times of outpatients, diagnostic patients, and admitted patients, which in most hospitals are held on separate computer systems. It is easier to link the waiting times together towards the end of the patient pathway, once their activity has been coded from the early stages, than to link it together while they are still partway through. Nevertheless, data on incomplete pathways has been collected since August 2007, so I have to say I think the change could have been made earlier.

But we are there now, and it looks pretty good. The main penalties discourage over-18-week backlogs from building up, and in the coming months this should lead to further satisfying falls in long-waiters. We also have hefty zero-tolerance penalties where any patient is still waiting a year after referral, which should at long last bring those extreme long-waits to an end. With the focus returned to the waiting list where it belongs, providers are now encouraged to focus on the fundamentals: keeping the list size down and scheduling patients in the right order. That’s better for patients, better for the service, and much less confusing for the public.

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