Monitor is out to consultation on how it should judge NHS Foundation Trusts, and performance against the “18 weeks” targets is part of the mix. The deadline for responses is 4 April 2013, so this is a good opportunity to influence their proposed approach and fix its unintended consequences.

Monitor’s proposed approach

The place to go is page 78 of the consultation document. There are 28 targets and indicators, ranging from waiting times to C. Diff. to medication errors. Monitor propose that:

NHS foundation trusts failing to meet at least four of these requirements at any given time, or failing the same requirement for at least three quarters, will trigger a governance concern, potentially leading to investigation and enforcement action.

and each of the three 18-weeks measures is included as a separate indicator in the list:

• Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted: threshold 90%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted: threshold 95%
• Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an
  incomplete pathway: threshold 92%

accompanied by the following note:

18 weeks referral to treatment: Performance is measured on an aggregate (rather than specialty) basis and NHS foundation trusts are required to meet the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure for the purposes of the Risk Assessment Framework. Failure in any month of a quarter following two quarters’ failure of the same
measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. Failure against any threshold will constitute a governance failure. The measures apply to acute patients whether in an acute or community setting. Where an NHS foundation trust with existing acute facilities acquires a community hospital, performance will be assessed on a combined basis.

Monitor will take account of breaches of the referral to treatment target in prior quarters (i.e. under the Compliance Framework) when considering consecutive failures of the referral to treatment target under the Risk Assessment Framework

Response

As usual with consultations, it isn’t always easy to tell which of the consultation questions is the right one for any particular issue. For this response, I’ve gone for Question 10:

Chapter 4 Question 10: Do you agree with the proposed approach to downgrading the governance rating – and ultimately finding a foundation trust in breach – as a result of either unresolved concerns for significant periods or concerns across multiple categories?

No (with regard to the “18 weeks” access targets)

Please provide more details:

Appendix A includes the three “18 weeks” access targets, and each target is considered independently when assessing the number and duration of failures. Unfortunately this approach has unintended and undesirable consequences.

Consider the following scenario : a Foundation Trust has developed a backlog of over-18-week waiters on its waiting list. Because of this backlog, it starts to breach the incomplete pathways target.

The most desirable cure for the backlog is to treat those long-waiting patients as soon as possible. Unfortunately, the current approach deters the FT from doing so.

The reason is that if the FT admitted all those over-18-week waiters, it would be likely to incur a second breach (against the admitted patients target). FT Board members have a strong incentive to avoid this further breach (especially if they are also breaching any other measures) by using a well-established tactic: taking care to admit only one long-waiter in every ten admissions. This severely restricts their ability to do the right thing and treat the backlog, and the proposed approach is therefore a perverse incentive. Put another way, for every long-waiter they admit, they must find nine short-waiters to admit out of turn; this is unfair to patients, and all that queue-jumping pushes up the longest waiting times.

So what should be done?

Ideally the admitted and non-admitted targets would be deleted. But I anticipate that this suggestion might not be acceptable, because both of those targets are currently specified in the NHS Standard Contract 2013/14 as well as the regulations underpinning the NHS Constitution.

So I would like to propose an alternative solution: that the three 18-weeks targets should be lumped together into a single-failure bundle. So a failure against any (or all) of them would only be one failure in total. Then, if an FT is breaching on incomplete pathways, it would not incur any further breaches by treating its long-waiters, so the perverse incentive is removed. The intended incentive (to avoid long-waiters building up in the first place, monitored across all three measures) is nevertheless preserved.