Some see the abolition of central performance management of the 18 weeks referral to treatment target as a big mistake, others think it heralds a more flexible system. Alison Moore looks at the early outlook for a controversial change of policy

Two views are emerging of health secretary Andrew Lansley’s announcement on the removal of NHS targets - especially the abolition of central performance management of the 18 weeks referral to treatment target.

Waiting times equal suffering. Waiting is so iconic to the public

One is that it is a tremendous misjudgement, which will lead to waiting times increasing dramatically as managers decide the pressure is off.

The other, more favourable, interpretation is that he is replacing a blunt target with a much more sophisticated system of levers and pressures, which will largely maintain performance but will remove some of the obvious perversities the “command and control” system imposed.

Much will depend on how the changes are communicated to and interpreted by local NHS bodies: former NHS chief executive Nigel Crisp told The Times last week that it was not clear what the changes meant and questioned how the message would be read by those on the ground.

The first view sees Mr Lansley potentially throwing away some of the advances made in the last few years. According to the King’s Fund, the 18 week target led to a dramatic fall in average waiting times as well as the longest ones. In 1997, these stood at 13.2 weeks for inpatient care. In 2004 - when the target was announced - it had fallen to 10 weeks but in March 2009, when the target had been achieved, it was just four weeks, although it seems to have risen since then.

Nuffield Trust director Jennifer Dixon accepts that there was “the odd perversity”, where clinical priorities were distorted. But overall there was a real benefit to patients from shorter waiting.

“Waiting times equal suffering,” she says. ‘Waiting is so iconic to the public.”

But opponents of this view argue that the perversities have been more widespread than this - and the “achievement” far less. The announcement could signal a very different management approach, under which the centre will not micromanage but decision makers will still be held to account.

Royal College of Surgeons president John Black says not only were surgeons forced to override clinical priorities to treat less urgent patients, but there was a loss of continuity of care with more pooled waiting lists.

The cost to the NHS of getting to this point has also been significant. Foundation trusts have seen their profit margins dip recently - thought in part to be due to the costs of pushing some specialties towards 18 weeks. And while more than 90 per cent of admitted patients are treated within 18 weeks, the situation is fragile and liable to be affected by the financial squeeze.

King’s Fund chief executive Chris Ham says: “Even if there had not been a move away from 18 weeks as a performance management target, the funding pressures would raise questions about how sustainable 18 weeks was. If you end up having to pay your own staff a lot more or spot-purchase in the private sector then it will have a significant price tag.”

The biggest surgical specialty - trauma and orthopaedics - has never achieved the 18 weeks target. British Orthopaedics Association president elect Peter Kay says 50 per cent of providers failed to meet the target in March 2010. Increased emphasis on achieving the target from mid 2009 has increased pressure on the specialty, with many patients being treated in the last two weeks of the target.

He argues that the abolition of the target should be used as a breathing space to develop high quality sustainable services.

Various factors

Which view of Mr Lansley’s actions is right will not be obvious for some time but the success of his new system will depend on a number of drivers that will interact to force providers to concentrate on swift treatment. These include the continuing presence of 18 weeks in the NHS constitution; how commissioners will react; how patients will exercise choice in a competitive market; and whether regulators will still look to 18 weeks when measuring organisations’ performance.

Dropping central performance management of the 18 weeks target does not remove it from the constitution. Patients will still have a “right” to ask their primary care trusts to look at alternative providers. But there is a question: how many patients, having got onto one waiting list, will go to their PCT and request that - especially if the alternative providers are some distance away? Very long waiting times might encourage them to do so but the difference between their provider and others would have to be significant.  

Commissioners - both PCTs and practice based commissioners - could start to insert 18 weeks clauses in their contracts with providers. Professor Ham expects to see these and says that “wriggle room” will be very limited. Any penalties are likely to be financial, whereas the present performance management system has resulted in the departure of chief executives. 

The success of this will depend on the willingness of commissioners to push - and Dr Dixon points to the weakness of commissioning at PCTs and the undeveloped nature of practice based commissioning. Mr Black, however, argues that under fundholding, GPs did become good at getting what they wanted out of providers.

It is possible commissioners may adopt a more subtle approach, perhaps asking for quicker treatment for urgent cases - something many surgeons would support. But could this mean that patients classified as non-urgent could wait longer? NHS Alliance chief executive Mike Sobanja suggests such exceptions would still have to be justified locally.

Choice might seem a more powerful driver. Given a range of providers, some of whom treat quickly, some of whom do not, patients will opt for the quicker treatment if they value this. But this relies on patients having good information about waits. If GPs push patients towards the local district general hospital, regardless of waiting times, choice may not be exercised and there are obvious problems if individual consultants are too popular. And there will be patients who have limited choice - those with co-morbidities who may need more complex care packages not available from private providers. If waiting times rise in NHS hospitals, they could be adversely affected.  

Other options

But for most patients there will be other options and many independent providers will be keen to emphasise their short waiting times; this competition may encourage NHS providers not to allow much slippage.

Foundation trusts - which often have a better grasp of the cost of individual treatments - will have to weigh up the cost of pushing towards 18 weeks against the potential loss of patients who opt to go elsewhere; at the margin this could mean they are reluctant to spend significant amounts of money pushing specialties from 89 per cent to 90.

But this could be affected by how regulatory bodies will treat achieving 18 weeks: the Care Quality Commission says it has to discuss with the government how it treats it in future and Monitor’s board is meeting to see how the revisions to the NHS operating framework affect its compliance requirements. Monitor’s latest quarterly report shows 16 breaches or risks of breaches of the 18 week target, all but one for the admitted target. Nine months ago, there were only four, which suggests that some trusts are struggling to sustain 18 weeks; this has contributed to more than half of acute foundation trusts being red or amber rated.

So will we see longer waiting times? The combination of the change in emphasis and financial pressures may lead to this. Mr Black points out there may be an immediate “bounce” as hospitals are more honest about their waiting lists.

Dr Dixon points out the interesting comparison with accident and emergency, where the target has been relaxed but not abolished for this year; if the A&E target is still achieved but 18 weeks is not, it could indicate that performance management really is the key to improvement.

As in many other policy areas, there may be lessons from Sweden. It introduced a maximum waiting time in 1992 and, when it proved hard to achieve, dropped it. Within a few years waiting times were extremely lengthy - the then prime minister waited nine months for a hip replacement despite being in considerable pain. In 2005, the guarantee was reintroduced and the hard task of reducing waiting times to a reasonable length was started again. Mr Lansley will be hoping he has devised a system which will avoid a similar fate.

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