Polly Toynbee’s piece on waiting list fiddles attracted a lot of attention, and quite right too. Within hours of being published, it was even being mentioned in the House of Commons at Health Questions.

Toynbee reported that:

The national target says 90% of patients must be treated within 18 weeks of first referral

and this has unpleasant consequences. A waiting list clerk, who resigned on principle, said:

She was told to cancel operations for anyone who was already waiting over 18 weeks, and instead to fill that theatre time with people closest to breaching the 18-week limit.

and

She was told not to book anyone already in breach until April and the start of the next financial year, or to book only one for every nine still under the target. Instead she was told to fill theatre slots with as many short, minor operations as possible.

This happens. It shouldn’t, but it does. The immediate and natural reaction is to blame the managers who gave the orders, but they are also just pawns in the game.

Imagine you are responsible for delivering the target for surgery in an acute general hospital. It’s now late February, so all the operating lists are nearly full for March, and new bookings are being made into April.

Let’s say you have booked 1,000 patients in March; 895 will have waited 18 weeks or less on the day of their operation, and 105 will have waited more than 18 weeks. The target says that 90 per cent must have waited less than 18 weeks, and you are heading for failure with only 89.5 per cent. What do you do?

You don’t have many options. If you breach the target, your Trust may receive a heavy fine from commissioners under the standard NHS Contract, and be subject to “performance management” by the SHA or Monitor; and you personally may be summoned to “explain yourself” to the Director of Operations or Chief Executive. Not an attractive option.

Or you could book in some extra under-18-week patients to bring performance up to 90 per cent. But that means finding operating time for 50 extra patients, and your lists are already nearly full. To make matters worse, you have used this tactic before and are running out of minor operations to pad out the target. Finances are tight, and you can’t afford to pay extra for lots of Saturday lists. So this option is not attractive either (and by using this option in the past, you have made today’s problem worse because your waiting list is now skewed towards heavier cases).

Which makes you think: you’re only 5 patients adrift of the target. If you just put 5 long-waiting patients off until April, and recycle their operating time for shorter-waiting patients, then you’re done. If you can choose five patients who are just about to breach 18 weeks then you have headed off your next problem too…

You can see how easy it is. Yes, it’s wrong, but in the circumstances what else can you do?

Following the story up at national level, Toynbee said: “Professor John Appleby of the King’s Fund health thinktank says he hears of waiting-list cheating from many hospitals and will suggest the National Audit Office investigates” and she asks whistleblowers to get in touch with her. Both are excellent ideas.

But we need to take care not to turn this into a punitive witch-hunt against cheating hospitals, because the targets and associated performance management are the root causes. So instead of prolonging the damaging treatment-based waiting time targets for another year, let’s abandon them now and move straight to the new waiting-list-based target instead. That, at a stroke, would eliminate the main cause of the problem.