What's happening to NHS waiting times?

In November last year we reported on waiting times standards, trying to track the impact of the extra £250 million provided to the NHS in order to improve performance.

This money was meant to pay for extra activity with two aims: to reduce the number of those on the waiting list who had been waiting a long time, but also – once this group had been taken off the list – to help bring waiting time targets, which had begun to slip, back into line.

Alongside the money came some top-level performance management, with Jeremy Hunt chairing weekly meetings with NHS leaders and ministers, including Eric Pickles and Oliver Letwin, underlining the political significance attached to waiting times in general.

National waiting time performance was meant to be back on track by the end of the year so, with the new waiting times data released this week by NHS England, how have things been?

The headline from the latest data is that all referral-to-treatment performance standards were met in December 2014 – this is a huge success for the NHS. It’s particularly encouraging that the waiting times target has been met for those requiring an admission to hospital for treatment, as this target had not been met for the previous six months in a row.

The waiting times for outpatients (or non-admitted patients) had missed the target in November 2014 for the first time in six years but is now back on track.

While all three referral-to-treatment targets are now being met, it is by narrow margins, and performance for patients yet to begin their treatment (patients still waiting) actually worsened in December.

Was the NHS also successful in achieving the aim of reducing the number of those waiting a long time?

In his speech in August 2014, announcing the additional activity, Jeremy Hunt stated that the number of patients waiting more than a year to begin their treatment should be ‘as close to zero as possible’. When this announcement was made, 532 patients had waited more than a year to begin their treatment; in December 2014 this had reduced to 399. With 207 of these patients (52 per cent) waiting for treatment from just one NHS provider, this does not seem to be a system-wide problem.

Without a clear definition of what counts as 'long waits', it isn’t easy to provide a broader verdict. There was a reduction in the number of patients waiting more than 26 weeks to begin their treatment from the time the Secretary of State made the announcement, but in the most recent data this jumped up by more than 9,800 patients. This might suggest that in December the attention of the NHS switched from reducing the longest wait to hitting the performance standards.

Does this place the iconic 18-week target on a firm footing for 2015? We think not for three reasons. First, the number of organisations failing to report their waiting times continues to rise. NHS England estimates that for December, nearly 250,000 patients were waiting in these organisations – this is an alarmingly high number.

Second, once we add these lost patients back into the statistics, the waiting list sits stubbornly high at 3.2 million. Sustaining performance will be challenging against this backdrop, not least when performance is already so close to the wire.

Third, separate data suggests the NHS ramped up (cheaper) day case activity in December by nearly 40,000 over December last year. The number of `ordinary admissions’ (ie, admissions that require an overnight stay) actually fell; however, these patients are generally more expensive and more complex to treat and, in some cases, will compete for beds with emergency admissions. With the NHS under pressure in January as emergency admissions rose, the problem of long waits for this group may prove more intractable.

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Comments

#542872 Darren Kilroy
Clinical Head of Service for Emergency Care

There's a paradox in healthcare narratives which we really must face up to and address.

One the one hand, we wring our hands over the inability of the care system to consistently attain a whole range of targets, many of which have no basis in evidence and most of which have become an operational pre-occupation eclipsing all else within NHS organisations.

On the other, we seek to address the findings of reports that describe shockingly low standards of human care and compassion right under the nose of that very same system which is bogged down by data, spreadsheets and weekly returns.

Until we honestly recognise that the former of these two conundrums is doing little to reduce the prevalence of the latter, we will fail to move forwards in enabling and sustaining a truly fit-for-purpose system of healthcare.

#542875 Rob Findlay
Director
Gooroo Ltd

"The headline from the latest data is that all referral-to-treatment performance standards were met in December 2014 – this is a huge success for the NHS. It’s particularly encouraging that the waiting times target has been met for those requiring an admission to hospital for treatment, as this target had not been met for the previous six months in a row."

I disagree.

Achieving the admitted target is easy: a hospital just has to make sure that, every time they admit an over-18-week waiter, they also admit nine under-18-week waiters in the same month. Because this target is so easy to manage to, its achievement is not a 'huge success'.

The effect of this target is to restrict the number of long-waiters the hospital is allowed to treat; it can only devote 10% of its capacity to them. So achieving this target, at a time when lots of long-waiters remain on the waiting list, is not 'encouraging'.

The non-admitted target works in exactly the same way, except that it imposes even tighter restrictions on the numbers of long-waiters the hospital is allowed to treat; only 5% of capacity may be used for long-waiting non-admitted patients.

So admitted and non-admitted performance only tells you how the NHS is selecting patients for treatment. It does not tell you the size of the waiting times problem, only how the NHS is responding to that problem within the restrictions imposed by the targets.

The incomplete pathways standard, on the other hand, does measure the size of the problem. It looks at the number of long-waiters who remain on the waiting list. As you rightly note, performance on this measure is deteriorating. The re-imposition of the admitted and non-admitted targets is accelerating this decline by restricting the NHS's ability to treat its longest-waiting patients.

Up and down the NHS, managers are intensely frustrated by all this. They want to treat their long-waiting patients, but the admitted and non-admitted targets force them to give priority to short-waiters instead. So they cannot continue to clear their backlogs, and those patients who have already tipped over the 18-week mark are left stranded on the waiting list.

This is unfair to patients. And it is also unfair to the NHS, because managers are being punished for treating the longest-waiting patients and applauded for keeping them waiting.

Success? Encouraging? Hardly.

#542892 Richard Murray
Director of Policy
The King's Fund

Rob,

In James’ absence I wanted to come back on some of the issues you raise.

We certainly agree that the reduction in performance on `still waiting’ is disappointing and that it suggests that the NHS chased the formal targets as a priority. Where I think we would disagree is the statement `achieving the admitted target is easy’. If only this were so. Until 2008 the NHS was bedevilled by long waits for as long as records can tell – waits that were both common and very long. Anecdotal discussions with many NHS providers over the last months have underlined how hard they have had to work to get any element of RTT back under some degree of control. Sitting behind this struggle is the combination of rising demand and increasing financial difficulties. This means that the simple fact of managing the list by admitting people is no longer straightforward to achieve (or afford) however long they may have waited. In this context it is perhaps not surprising that the national NHS is performing above the target by the smallest of margins and, of course, many local areas are not managing that.

It does mean that over the next months the pressure remains on for the NHS to deliver RTT targets on admitted and non-admitted patients whilst still delivering the `still waiting’ target. On all three measures the NHS has very little room to manoeuvre.

#542896 Andy
Intelligence Analyst

Whilst I'm not disputing the content of views of the above, what people constantly fail to consider, is how flaky the RTT reporting mechanism is. Whilst the old outpatient and inpatient waiting returns (QM08 and KH07) didn't cover the full pathway, it was possible to discretely count the records and monitor the performance. Given that each PAS supplier will have differing methodologies to their RTT calculations, some Trusts will then be processing and reporting this data outside of their core systems, from warehouses where data can have criteria applied and records filtered out and no real triangulation from CDS returns being done... It begs the question of 'how accurate are the figures being reported'...

Having worked on both sides of the fence, one half of the sector doesn't understand how the Trusts process and generate their data and the Trusts know this. Not sure where the SUS RTT reporting methodology got to that I trailed sometime ago but I suspect nationally compiled figures from the raw data would be very different to what Trusts are submitting performance wise.

#542903 elaine carter
gp
nhs

this 18 week target has skewed clinical priorities in practice more than any before

#543781 Noel E
Wait Times Consultant
W8TX Insights

A bit late but throwing in my two-pence worth:

In 2014, admitted waits failed and non-admitted and incompletes just marginally passed.

Given this performance, especially relative to its run-rate in years before, I agree with Robert, the report is hardly a success but I agree with Richard it is not easy - what with the dynamics of demand/supply, state of wait time data systems/practices, staff training on RTT standards/analysis.

What really concerns me is just how submitted reports are just ‘close to the wire’ or 'above target by smallest of margins’. Being a trained auditor, I can’t help to think whether these figures were reliable - issue that Andy rightly pointed out.

Lo and behold, just early last year, NAO found that it was not so - even reporting >50% lacking documentary support or were incorrectly recorded. Even the published data assurance checks of NHS England is mostly limited to the way return template is filled out (missing section, sums check).

Fortunately, as provided on HM Treasury’s 55th report, NHS England’s response to NAO audit report planned to have Monitor and TDA mandate data assurance on waiting times data from April 2015 (given we’re now in May, I wonder how it is going).

James asked for definition of a long wait. Without a doubt, >52 weeks is too long a wait or even anything approaching one year. If you measure performance at 18 weeks, any wait past that is, by definition, already a long wait in my view.

James mentioned 52-plus-week waiters may not be a system-wide problem. In truth, there were 37 other providers out of some 190 on the list with one to 48 patients waiting over a year. That’s 1 in 5 trusts. Curiously, there were other 26 trusts with combined 55 patients waiting 52 weeks and 15 more with combined 22 more patients waiting 51 weeks. Now, that’s 79 trusts representing 42%. I will suspend my judgement until I get the number that represents the standards' operational tolerance so I can back out those providers with legitimate waits - by patient choice or non-cooperation or clinical exceptions - which I even wonder if available at trust-level.

Robert emphasised incomplete pathways as 'measuring the size of the problem.’ But the 399 long waiters that James mentioned were in fact incomplete pathways. So, I was lost there somehow.

Robert also said providers 'can only devote 10% (or 5%) of provider capacity’. I have yet to read an NHS England guidance or provider access policy that such is the operational fact, 'way to do it’, constraint or requirement. On the contrary, providers are required to treat patients according to clinical priority then according to wait, a best practice that even NHS IMAS has a guidance published.

The best takeaway here, as Elaine alluded to, is the perverse incentive of treating patients still within target over breaches in order to report hitting the wait targets. We already know this is happening. But how do we solve this? My take is that we enforce the patient prioritisation requirement of clinical priority then first-in-firs-out. Easy to say but difficult to do. Trust CEOs should lead to enforce this with information teams aiding in this goal.

Any resulting breaches or long waiters need to exclude legitimate waiters. We can then analyse what is attributed to demand pressure, capacity constraint or processing delays that inform operational and strategic decisions to solve and prevent the problem.

Lastly, I would like to emphasise what you already know that we need:
1. to enforce data assurance controls to generate reliable data;
2. to develop more robust analytical and management tools to ensure effective patient tracking;
3. to educate staff on RTT rules and wait data analytics to promote meaningful insights and actions;
4. to quantify demand pressures and capacity constraints to identify what NHS IMAS calls the excess wait or backlog; and
5. to have NHS England to collect more data (and audited at that) that will better inform performance and regulation (e.g. legitimate waits, measure of patient prioritisation compliance, etc.).

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