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The 18 week target

Eighteen weeks is one of the biggest successes of the NHS in the last decade. Only a handful of trusts have missed the target and more than 90 per cent of patients across England are now treated within four and a half months of referral. It’s all a long way from the dark days of 12 month waits for outpatient appointments and 18 month waits for surgery.

Given this success, it would be easy to shift attention away from waiting times – long lists and waits might seem a thing of the past, after all. Unfortunately, February’s snow showed just how difficult sustaining 18 weeks can be. And while the weather has now improved, the long term economic outlook is much bleaker.

Looking back to the early days of the 18 weeks policy provides an interesting lesson. Back in 2004, the details of the 18 weeks target were being thrashed out. At the time, the guiding thought was to move the national debate beyond waiting times, just as had been done for unemployment. In 2009, with unemployment numbers firmly centre stage once more, the parallel with waiting times is all the more important.

There’s more to this than analogy – as the economic downturn bites and unemployment rises, so tax revenues drop and bank bailouts mount. The financial settlement for the NHS will undoubtedly be squeezed as a result. In this climate, how confident can we be that long waiting times really will be consigned to history?

While there are no magic bullets, by applying the six principles below we believe clinicians, managers and Boards can feel more confident in their ability to both sustain and better their current waiting times performance.

1. Continued vigilance and a culture shift is needed to sustain performance

Clinicians and managers have seen how quickly performance can slip on target such as four hour A&E waits and MRSA infections. In contrast, much has been made of the ‘non-recurrent’ nature of the additional activity required to reduce the backlog of long waiters and how a steady-state situation, with lower activity, will occur once the 18 week target has been achieved. Unfortunately this may be true in theory but in practice it is entirely possible for providers to go backwards on performance. This can be due to any of a number of reasons, from insufficient capacity to reduced productivity to increased demand (at any stage of the pathway). Old challenges such as emergency pressures exacerbate the problem.

More subtlely, clinical and management attention can easily drift. It would be naive to believe that 18 weeks can (or should) always be the number one priority for chief executives and their organisations. Therefore, while continued vigilance and leadership are critical to ensuring that performance doesn’t slip in the short term, a more effective solution is to embed a cultural change so that short waiting times become second nature.

This is of course difficult to achieve. However, our experience shows that critical to success in culture change is ensuring that all four of the following dimensions are in place:

  • Respected role models in the organisation ‘walk-the-talk’ – front line clinicians and managers as well as executives
  • The benefits of change are clearly articulated – staff within hospitals and PCTs understand the need for change and what benefits it brings to them personally. We have seen examples where whole surgical teams attitudes change when the leader of the team identifies that success with sustaining waiting time reductions helps to improve their standing within the organisation but also more importantly generates income that helps to support developments in their area.
  • Necessary capabilities are in place or training made available – staff are confident that they will be able to act in the way their leaders want them to. Training for booking staff is a one such crucial group of staff and support for staff on validation, booking practices and customer care training has proved invaluable in areas where low waits are integral to the culture of the organisation.
  • The supporting processes, tools and systems are aligned with the new way of working – from management of performance to proactive patient tracking, people need to be supported, not ‘fighting the system’

2. Stage of treatment monitoring is no substitute for management based on referral-to-treatment time

Given the strong and necessary DH focus on inpatient and outpatient waiting times in the first half of this decade, it can be very tempting for NHS managers to continue to use the stage of treatment milestones as the mainstay of their management of the 18 weeks target. However, managing to stage of treatment alone leads to serious problems for sustaining and bettering 18 weeks:

Key elements of the referral to treatment pathway (e.g multiple outpatient appointments and diagnostic tests) are not effectively captured

Speeding up one element of the pathway, say outpatient, without understanding or planning for the knock on to other elements, can create an unmanageable bottleneck

It can lead to patients falling between the stages of treatment and creates the potential for increasing the likelihood of using pauses and suspensions

RTT works best when administrative and clinical pathways line up and is a real change for the administrative teams. Moving to one approach as soon as possible will prevent confusion

Without doubt, the move from stage of treatment to RTT management is a difficult one. Nonetheless, it has proved successful for trusts that have done so. While there will always be reasons to maintain the old approach, it is better to move to RTT management now – it is after all much more closely aligned to the realities of the patient journey.

3. Ensuring patients understand referral-to-treatment pathways and the very low waits that now exist will help them to participate in the fundamental change 18 weeks can and should create

Within the new NHS Constitution, significant store is set by the NHS being clear about its role and responsibilities but similarly sets out patient responsibilities too.  Moving to a sustainable position on RTT is a good example of how both the NHS and patients will need to change to achieve this outcome.

More specifically provider organisations and commissioners will need to be transparent about their policies and procedures linked to RTT ‘rules’ including pauses and referrals back to GPs as well as communicating more clearly about appointment dates. The Operating Framework 2009/10 states “no one should wait more than 18 weeks from the time they are referred to the start of their hospital treatment, unless it is clinically appropriate to do so or they choose to wait longer”. Providers and commissioners should be working to 18 weeks or below for all patients – ‘managing to the tolerance’ by offsetting historically long-wait specialties (e.g. orthopaedics) with shorter wait services will lead patients continuing to experience long waits feeling short-changed. Such an approach may achieve the target but would certainly miss the point of the original policy.

A good example would be to reduce the current level of ‘outpatient churn’ that exists in hospitals when patients have appointments for follow up appointments moved more than once due to operational reasons within the hospital. Reducing this would improve the quality of service to the patients and also improve the efficiency of the service for providers. Patients will need to assist in the management of pathways by keeping providers informed of decisions about their care and changes in their personal circumstances.

Sustainable systems will also require RTT to align strongly with what patients want – it will be of limited value if the NHS claims success on reduced waiting times if the patients feel as if they have been processed through a system that does not take account of their individual needs.

The increased focus on patient and public involvement through surveys, patient initiated feedback, exit interviews and specific focus groups will help to embed RTT. It should also help patients feel a part of turning RTT into a sustainable change that transforms how the NHS manages patients’ elective journeys through the system. Without such a change it is likely that all the efforts to date will not be recognised as the significant improvement they are. Furthermore, the change will be less likely to be sustained and the importance of continuing to push the boundaries on waiting times as an increasingly important choice lever will be lost.

4. Genuine GP engagement is needed alongside secondary care.

Many PCTs have set aggressive demand management plans in response to the challenging financial situations they face. Nonetheless, 1st outpatient appointments grew on average by 10% in Q2 08/09 (the latest quarter for which data is available) compared to the same period in 07/08. This demand increase heightens the challenge of maintaining and bettering 18 weeks considerably.

In this context, GPs hold many of the key levers for achieving the target:

As practice-based commissioners, they are able to limit acute demand, only referring those patients genuinely in need of acute care

As alternative providers, they are able to compete for existing acute work

Effective communication and transfer of patients from acute care back to GPs improves referral-to-treatment times

They impact significantly on a patient’s understanding of the pathway.

For demand for acute services to drop (or at least for demand growth to reduce), GPs will need to genuinely feel that demand management benefits them and improves the service for patients … and is therefore not an unnecessary, managerially-imposed requirement. This requires strong clinical leadership within PCTs. Ultimately, successful demand management requires GP champions and real secondary care engagement and involvement in the work-up and implementation of new pathways.

5. Once the majority of the patient backlog has been cleared, investment in additional treatment activity is more cost-effective than investing the same money in outpatient and diagnostics

Inpatient, outpatient and diagnostic waiting lists need to be low enough for all patients to be treated within 18 weeks. A 12 week first outpatient pathway won’t leave enough time for tests, further appointments and treatment.

Clearing this large backlog of patients can temporarily bring down the percentage of patients being seen within 18 weeks, as many if not all trusts have seen. This seems counter-intuitive but many of the ‘backlog’ patients were referred more than 18 weeks previously. They therefore appear as breaches in the statistics when treated but not while they are awaiting treatment.

Some trusts and PCTs will be tempted to reduce outpatient and diagnostic waiting times to an absolute minimum level (e.g., 2 weeks). Where this is carried out as part of a planned reduction in waiting times at all stages of the patient journey, the approach is sound. When done in order to allow longer waiting times for the relatively expensive inpatient and daycase treatment, the logic is faulty.

The waiting time for admitted patients is affected only by the number of people ahead in the ‘queue’. Even if more outpatient and diagnostics activity is carried out (in order to reduce waiting lists), a patient who will need admission still has the same number of ‘to be admitted’ patients ahead of them and will still (all else being equal) have the same referral to treatment time. The effect of reducing outpatient and diagnostic waiting times is to list patients for inpatient or daycase sooner - but they will not be treated any more quickly unless additional inpatient or daycase activity is also carried out.

If the money is instead used to increase treatment activity, the referral to treatment time genuinely does decrease (as the number of people waiting for treatment ahead of a newly referred patient will decrease). Increasing treatment activity may well therefore be a better use of money than increasing outpatient and diagnostic activity.

6. A shared approach to modelling and monitoring between PCTs and Acute trusts avoids time-consuming and relationship-straining disputes downstream

At present, PCTs and trusts often develop separate analyses with different assumptions and significantly different results. The protracted negotiations that follow may lead to an activity settlement that neither side is happy with but are forced into by contract deadlines and other calls on management time. Disputes over the activity (and so cost to PCTs / revenue to acutes) required to sustain and better 18 weeks are then very likely. This issue is avoided if the modelling and monitoring of activity and finances is shared and agreed between both parties.

Such analyses should start by developing a shared understanding of current and future capacity (e.g., staff, beds, theatres, diagnostics, outpatient slots) and demand, and the variations in these. This can then be translated into activity requirements along the pathway, taking into account productivity improvements. Importantly, capacity needs to match demand day by day (and specialty by specialty), not just on average otherwise lists will build up on those days where demand exceeds capacity but will not reduce on days where capacity exceeds demand.

Matthew Kershaw is chief executive of Salisbury Hospital foundation trust. Paul Bate is a Director at 2020 Delivery, a management consultancy.

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