What next for “18 weeks” policy?

by Rob Findlay

Government politicians must be feeling slightly frustrated with England’s elective waiting times. Not because waits are bad, far from it. They’re good. Really good.

The problem is, they’ve been good for ages and the previous Labour Government can take the credit for that. The Coalition have toned and improved them, but it’s hardly front-page stuff. And now there are worrying signs that the waiting list is growing again, a sign of trouble to come. What, then, could an ambitious politician do to get kudos for waiting times?

The conventional approach would be to ratchet the targets down from 18 weeks to 15, say. Or raise the standard from 92 per cent to 95. But the problem is not that the former is difficult and the latter arcane, but that it would probably do more harm than good.

If you have a dodgy knee then your hospital has less than 18 weeks to see you in outpatients, give you a scan if you need one, and operate: that’s only 6 weeks per stage. The short waits are great, but being operated on is a big deal and some patients can already feel a bit rushed especially towards the end. That’s also why the target is for 92 per cent of the waiting list to be within 18 weeks, not 100 per cent, so that some patients can wait a little longer if they want to.

The effect on NHS behaviours would be even worse. We have seen in recent years how the admitted patient target deterred hospitals from treating long-waiting patients, and thankfully that target has now been downgraded. But the new waiting-list-based targets also have the potential to distort, and we will inevitably see some hospitals respond by limiting the availability of Choose & Book slots, cancelling patients who are not covered by the target, over-relying on expensive ‘waiting list initiative’ sessions, and perhaps even distorting clinical priorities or fiddling the figures.

That is an issue with waiting times targets generally, and yet they do serve a purpose. Labour famously achieved 18 week waits using ‘targets and terror’. The Coalition had a go at lifting central controls on 18 weeks and were promptly rewarded with longer waits; if they tried it again I am sure the same would happen.

So the waiting-list-based 18-week standards should not be abandoned, nor should they be tightened. Have we run out of options? Not at all. We just need to find another way of improving waiting times. But how?

The key to the puzzle is to look at how the targets distort behaviour, and notice that the problems are concentrated in the patient booking process. But waiting times management isn’t only about patient booking: keeping the size of the waiting list under control is equally important. The distortions arise when long waits are caused by a growing waiting list, but the hospital tries to use patient booking tactics to fix it. The solution lies in using the right tool for the job.

Which sounds perfectly reasonable, but there are interesting consequences.

The most important is that staff who book appointments for patients should ignore the waiting times targets. Their job is to fill the capacity available, book urgent patients (just) within their clinically safe limits, and book other patients (broadly) on a first-come-first-served basis. Local managers should monitor them against those objectives, but not against the waiting times targets.

With the patient booking process taken care of, waiting times will depend only on the numbers of patients on each waiting list. Lists need to be kept down, which is the responsibility of lots of people from service managers to commissioners. They need to understand the size of list that is consistent with their waiting times objectives, the activity, capacity and money needed to deliver it and keep up with demand, and how all those things are expected to vary week by week through the year. Then if the waiting list becomes larger than expected they need to do something about it.

All that is commendably service-led, but how can our ambitious politician make a difference? Here are three suggestions. Firstly, resist the temptation to ratchet the targets; just keep on simplifying them until only the waiting-list-based targets remain. Secondly, celebrate those hospitals who are brave enough to book patients according to clinical urgency and natural fairness without being skewed by target-chasing. Thirdly, expect hospitals and commissioners to plan that waiting lists will generally shrink rather than grow (but do it delicately, because you don’t want to deter hospitals from counting their lists properly).

That’s quite hands-off, but then the new structure of the English NHS is quite hands-off too. If we can keep on gradually shrinking the waiting list, then top-down enforcement of ’18 weeks’ will become rare and largely redundant, and eventually we will put an end to involuntary waiting for most patients. Best of all, the gains will have been driven by the NHS itself.

An earlier version of this post was first published in the HSJ
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