What on earth is going on with the Government’s referral-to-treatment waiting times targets?

In the last few weeks we have heard great things from them, showing that they now understand the problems created by the current target regime and want to move forwards. For instance the new Operating Framework says:

The operational standards of 90 per cent for admitted and 95 per cent for non-admitted completed waits as set out in the NHS Constitution remain. In order to sustain the delivery of these standards, trusts will need to ensure that 92 per cent of patients on an incomplete pathway should have been waiting no more than 18 weeks. The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.

Operating Framework 2012/13, para 2.31

The new target is very welcome and in a perfect world it would have completely replaced the old targets (which punish Trusts for treating long-waiting patients). But abandoning the old targets would have required amendments to legislation, and invited political criticism that the Government was letting go of waiting times, so it isn’t entirely surprising that they have been retained.

This new, better direction of travel was reinforced in the latest edition of The Quarter. It said:

In addition to sustaining and improving performance against the NHS Constitution operational standards, the NHS must also ensure that those still waiting longer than 18 weeks are treated as quickly as possible. As set out in the NHS Operating Framework for 2012/13, from next year trusts will need to ensure that 92 percent of patients still waiting for treatment (also known as incomplete pathways) have been waiting no more than 18 weeks. Therefore, the NHS needs to take action to treat patients still waiting over 18 weeks after referral, for reasons other than choice or clinical exception.

In particular some trusts are currently reporting an unacceptable number of patients still waiting more than a year for treatment after referral.

At the end of September 2011, five trusts were responsible for around half of those people still waiting more than a year for treatment (see figure 12). These trusts, and any other trusts that are reporting patients still waiting more than a year for treatment after referral, must take action to understand the reasons behind these long waits and treat any patients still waiting as quickly as possible.

The Quarter: Quarter 2 2011/12, p.11

Amen to all that.

Which brings us to the latest big publication, which in many ways is the most important. The NHS Standard Contract lays out in detail the precise targets and penalties under which the NHS will operate in the coming financial year. Now that the Government has shown that it both understands the problems created by the old waiting time targets, and has shown willingness to change its approach in helpful ways, I would have expected the new Contract to:

1. pay lip service to the old treatment-based targets and the regulations underpinning them around the NHS Constitution, but
2. remove the financial penalties that actually punished Trusts for treating too many long-waiting patients, and
3. replace them with a new penalty regime that punished Trusts for having too many long-waiters on the waiting list, in line with the new target.

(I’m not saying that creating a new penalty regime is necessarily the best way of going about this, just that it would be in keeping with the traditions of NHS management.)

So what does the Contract actually say? Here are the relevant paragraphs in all their glory (my emphasis below):

Subject to Clause 43.6, if in any month the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 (Nationally Specified Events) for any specialty, then the Commissioners shall deduct for each such specialty an amount calculated in accordance with Section B Part 8.4 and weighted in accordance with Clause 43.5, from any payments to be made to the Provider under this Agreement.

2012/13 NHS Standard Contract, Section E, clause 43.4

Technical Guidance Reference: PHQ19-20

Nationally Specified Event: Percentage of patients seen within 18 weeks in respect of Consultant-led Services to which the 19 Weeks Referral-To-Treatment Standard applies

Threshold: For admitted 90% and over And For non-admitted 95% and over

Method of Measurement: Review of monthly report under Clause 39.1 of the Core Legal Clauses

Consequence per breach: As set out in Clause 43.4 of the Core Legal Clauses and Section B Part 8.4

 2012/13 NHS Standard Contract, Section B, Part 8.2 on p.16

Percentage by which the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 for each specialty (in respect of Consultant-led Services to which the 18 Weeks Referral-to-Treatment Standard applies) [heads a table column, with bands running from 0 to over 10 per cent]

Percentage of the revenue, derived from the provision of the (underachieved) specialty in the month of the underachievement, to be deducted under Clause 43.4 subject to the cap of 5% of the Contract Month Elective Care 18 Weeks Revenue pursuant to Clause 43.6 of the Core Legal Clauses [heads a column with penalties running from 0.5 to 5 per cent]

 2012/13 NHS Standard Contract, Section B, Part 8.4 on p.26

Lots about the old admitted and non-admitted targets, then. But where is the incomplete pathways target? Nowhere.

What will this do to waiting times? It fundamentally undermines the Government’s stated intention to reduce the number of patients “forgotten” on English waiting lists. For all the Government’s fine words, the new Contract retains the penalties that punish Trusts for treating lots of long-waiting patients, and creates no new incentives for them to achieve short waits on the waiting list.

When money is tight, and Trusts have a statutory duty to balance the books, which of fine exhortations and financial penalties is going to weigh more heavily on peoples’ minds? (That was a rhetorical question.)

Personally, I am baffled. Why did the Department of Health not carry the new target through from the Operating Framework to the Contract? I simply do not understand it.

So here’s a little suggestion to DH. While you are correcting the typo that refers to a 19-week target, why not take this opportunity to change the penalty regime over to “92 per cent of incomplete pathways within 18 weeks”? If everyone’s off over Christmas, I’ll even help with the drafting.

Have a lovely festive break.

[Update: The NHS Standard Contract, Section B, Part 8.2 was amended by DH a few hours after this post was first published at HSJ blogs. They fixed the 19 week typo, but not the target.]