Historically, providers have managed waiting lists but it now makes sense for clinical commissioning groups to take the reins
Did you ever hear anyone say, perhaps rather cynically, that clinical commissioning groups are just rebadged primary care trusts? Yet the more you look at the detail, the clearer it seems that CCGs can do things very differently.
Take planning, for instance. Planning is surely central to commissioning and yet PCTs tended to let providers do all the work. One important reason is that providers had a virtual monopoly on the necessary information. PCTs could have insisted on getting hold of it but, by and large, they chose not to - and in the process they also left providers in control of how the planning calculations were done. Sadly, the simplest methods ignore the potential for better patient scheduling to reduce waiting times. PCTs lacked the expertise to challenge providers and so the resulting models tended to favour the providers.
For the future, though, CCGs have a statutory duty to plan, and to promote the NHS constitution and its 18 week targets when doing so. To do this effectively, they will finally need to get their hands on the necessary information: waiting list additions; removals; activity; current list size; clinical priorities; and how the list is to be managed, all by stage of treatment. So those parts of the NHS that have not yet switched off the old Körner returns would be wise to keep them going.
It makes sense for CCGs to get hold of waiting list data, but what about “ownership” of the waiting list itself?
The waiting list is the accumulated deficit between referrals needing treatment (mostly referred by GPs, all of whom are members of CCGs) and activity (mostly commissioned by CCGs). So the waiting list is mostly a CCG creation and should be a CCG responsibility. Historically though, waiting lists have always been “owned” by providers who, with justification, sometimes feel aggrieved at being blamed if they are too long. This arrangement has persisted despite several versions of the purchaser/provider split. Is it finally time for this to change, and for CCGs to own the list instead?
The waiting list is effectively a CCG’s order book. By handing the entire order book over to providers, CCGs let them rattle through activity faster than the CCG can afford, add patients to it without permission and, every now and again, embarrass them by breaching the 18-week targets. On top of all that, handing over the waiting list acts as a drag on what is arguably a CCG’s most important role: improving and integrating care pathways.
For example, let’s say a CCG managed to negotiate a shorter, better, and cheaper pathway for 100 patients with condition X. If the provider owned the waiting list, the CCG would have to wait for, and catch, the next 100 appropriate referrals, redirect them one by one along the new pathway and pay with new money. But if the CCG owned the waiting list, they could send 100 patients straight to the new pathway from the existing waiting list, and recycle the resource already allocated.
This stuff isn’t new; in 2010, Bexley Care Trust won three HSJ Awards for doing this kind of thing around community cardiology. But it is very QIPP.
There are other benefits too. For the increasing numbers of patients with long term conditions whose care spans several primary and secondary providers, CCGs are well placed to ensure appointments are coordinated sensibly, in a way that no individual provider could achieve.
CCGs have more options to make sure patients have timely appointments as they pass the 14 week mark, as well as to do things like arranging door-to-door transport where necessary (reducing the number of non-attenders being returned to their GP and needlessly re-entering the system), and avoiding nonsenses like patients attending the hospital only to find that their test results are not ready.
Existing waiting list administration, built up by providers over many years, is more a supporting infrastructure that copes with the backlog, rather than an enabler of better coordinated pathways. As CCGs take over commissioning, why not take ownership of the waiting list too and use it to start transforming the management and culture of waiting in the NHS?
Rob Findlay is founder of Gooroo Ltd and a specialist in waiting time dynamics.