How the NHS can chip away at 18 week waits

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 credit for that.

The coalition government has toned and improved waiting lists and stopped austerity from pushing them up, but it’s hardly front page news. What then could an ambitious politician do that would get noticed?

‘Labour famously achieved 18 week waits using “targets and terror”’

The conventional approach would be to ratchet the targets down from 18 to 15 weeks, say, or raise the standard from 92 per cent within target to 95 per cent. But the problem is not just that the former is difficult and the latter arcane; the issue is 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 six weeks per stage. The short waits are great but being operated on is a big deal and some patients can already feel 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 responding by limiting the availability of Choose and 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 ceasing central controls on 18 weeks and was promptly rewarded with longer waits; if they tried it again, I am sure the same would happen.

Distorted behaviour

So the waiting list based 18 week standards should neither be abandoned nor tightened. Have we run out of options? Not at all. We just need to find a way of improving waiting times without tighter targets. But how?

‘Staff who book appointments for patients should ignore the waiting times targets’

The key to solving this puzzle is to look at how the targets distort behaviour and to 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.

This 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 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 throughout the year. Then if the waiting list gets too big they need to do something about it.

Hands off

All that is commendably service led, but how can our ambitious politician make a difference? Here are three suggestions: first, resist the temptation to ratchet the targets − just keep on simplifying them until only the waiting list based targets remain.

Second, celebrate those hospitals that are brave enough to book patients according to clinical urgency and natural fairness, without being skewed by target chasing.

‘If we keep chipping away at the waiting list, the top-down enforcement of “18 weeks” will become rare and largely redundant’

Third, set an expectation that the number of patients waiting should generally fall rather than rise. But do it delicately, because you don’t want to deter hospitals from counting their waiting lists properly.

That’s quite hands off, but then the new structure of the English NHS is a bit hands off too. If we keep chipping away at the waiting list, the top-down enforcement of “18 weeks” will become rare and largely redundant and we will eventually put an end to involuntary waiting for most patients.

Best of all, the gains will have been driven by the NHS itself.

Rob Findlay is director of Gooroo