London Eye: Publish the priority scores for elective waits

What does GSTT object to?

Control of some specialised commissioning budgets is due to be passed to integrated care boards, but the association of giant tertiary centres (The Shelford Group — it is still there, post-Stevens) has come out against this.

You can see why they wouldn’t want these budgets, which determine the kind of work often very eminent clinicians do at prestigious trusts, in the hands of teams that might have little understanding of them. Comments on the report above showed a degree of scepticism about ICBs having the expertise to commission this work. But there was also cynicism about how much less scrutiny specialised commissioning’s cost inflation has received compared with the rest of the NHS.

What is more mysterious is what Guy’s and St Thomas’ Foundation Trust (a Shelford member), in particular, is objecting to.

GSTT’s most recent board papers said: “The NHS England and NHS Improvement London region should retain the budget for specialist work that was commissioned regionally.”

However, it’s not clear if it simply opposes ICBs taking control, or also wants to take delegated control of those budgets itself.

Putting the south east London providers in charge of their money has been floated before and is already an approach up and running for some specialist mental health services in south London, and elsewhere.

This is presumably something Sir Hugh Taylor (GSTT chair and long-standing interim chair at King’s College Hospital FT) will want to get finalised before his retirement, which is expected soon.

The question of who replaces Sir Hugh will likely be key for the direction GSTT goes in, not to mention being a test of how much the system considers King’s has been rehabilitated – and therefore could get its own independent chair again, rather than another shared arrangement. 

Long waits

London is the second-best region in the country for RTT performance. At 67 per cent, its proportion of the waiting list not waiting more than 18 weeks is beaten only by Yorkshire and the North East

That said the variation in the capital is pretty stark. South west London has the best performance in England by that measure, 75.7 per cent on the latest data. Pretty far removed from the other four clinical commissioning groups, which range from 68.8 per cent (south east London, 2^nd best) to 63 per cent (north central London, worst).

What explains this? SWL points to the maturity of its relatively long-standing networking arrangements, the trusts have been sharing the work out to avoid long waiters for a while. They were also one of the first places to do an elective orthopaedic hub (since aped in north central London and progressing in NWL).

St George’s University Hospital FT’s board were told at their most recent public meeting about a scheme to text ear, nose and throat patients before their planned procedure to ask if, actually, they still wanted it.

A significant proportion of them did not and could then be removed from the list.

What a difference from tariff days when they name of the game was throughput at all costs.

The pandemic and backlogs are going to keep changing things in electives.

You might ask whether the NHS should always have had a prioritisation system, like that introduced during the pandemic — ranking cases from priority one to priority four. There was already plenty of pressure on the elective system. Yes, the medics would prioritise people but the system as a whole was set up to maximise volumes. So there’s definitely lots that’s unnecessary and can be stopped.

One of the things that has been surprising about the periodic discovery of patients “lost to follow-up” or whose pathways had simply lost track of, was how little noise it made.

Perhaps the harm review processes were overly indulgent of hospitals that had done this but overall it seemed like lots of people simply hadn’t noticed they didn’t get a follow-up, so maybe they weren’t all that necessary?

But there’s still a danger to patients from asking hospitals to reduce the amount of work they do.

One waiting times expert told London Eye recently the most common question they were now asked by trusts was “how do I achieve a 25 per cent reduction in follow-ups?”

That’s surely a question for the medics rather than the people administering the waiting lists? Arbitrary asks like that risk putting real patient harm into the system.

And the P1-P4 system is far from perfect. Or even adequate, according to some.

GSTT published an interesting document on this recently acknowledging that the current system doesn’t always recognise different forms of harm, ie psychological harm and “pain”.

One in 20 patients do not actually have a P-number and “clinical reprioritisation is difficult to achieve at scale” – ie there is not enough doctor time to do all the assessments.

Why is regrading people’s priorities an issue? Because the initial “categorisation is procedure-based and insensitive” and “patient-level tracking is inadequate for all P2 and P3. Volumes are large and unsophisticated tracking could become a significant burden on clinical teams”.

There is not enough clinical time to treat everyone in a timely manner, let alone reassess whether people put into low priority categories are languishing dangerously.

The least the centre could do is make the information publicly available.

NHSE should publish the waiting times data by areas and by the P-numbers, otherwise it will start showing up in the NHS Resolution compensation pay-outs.