The must-read stories and debate in health policy and leadership.

A tale of two trusts

Many university hospitals have been around for hundreds of years (Barts nearly a thousand), pre-dating the NHS.

First, the district general hospitals of the 1960s and 70s, then the independent sector treatment sectors of the 2000s were set up by ministers anxious to get the bread-and-butter elective work the population needs done in bulk (the feeling being that academic medical centres tended to focus on the novel and the complicated at the expense of the routine).

So, tension between academic teaching hospitals and the wider system is nothing new. But south London gives two recent examples of the difficulties of reconciling such frictions.

Guy’s and St Thomas’ Foundation Trust has banned some referrals into its specialist paediatrics service in response to high demand from outside its inner south London boroughs. It is considering restrictions on some other services too.

Why has this happened?

Sources say work from overheated south east England DGHs and work that might otherwise have gone to King’s but for its huge waiting list problem now comes to GSTT. Not only this, but similar problems at Barts and Imperial have seen an increase in work from north London. The Thames used to be a bit of a wall of fire for referrals, with patients largely stayed their side of it.

GSTT admits the measures it has approved are in breach of the NHS Constitution (which, lest we forget, confers enforceable legal rights). It remains to be seen whether this infringement will be challenged or just another part of the Lansley Act that is worked around.

Meanwhile, GSTT’s neighbour to the south has also got capacity problems. Too much work in urology at King’s College Hospital Foundation Trust means patients are now re-routed to GSTT, while orthopaedics work is so overheated that the Royal National Orthopaedic Hospital in deepest north London is being considered for treating patients. King’s says it does not want to put large slugs of work out to the private sector.

It may not have a choice.

Because another problem for trusts trying to deal with their huge backlogs is patients reluctant to change consultant part way through their treatment. Not all healthcare can be commoditised. And that’s before you factor in the journey to Stanmore. Seeing your NHS consultant in private facilities paid for by the NHS may be inevitable for many patients.

How did King’s only recently come to discover England’s biggest backlog of year plus elective waiters? The fact that many hospitals’ data systems are not worth the pixels they are printed on might have something to do with it (see more below).

King’s is not the only London trust in this position, HSJ understands.

Data mismatch

Only insomniacs would rank trusts’ quality accounts high on their recommended reading lists – a pity as they are a cornucopia of details, shining a light on what is really going on in the NHS.

Among such details are the independent auditors’ verdicts, typically produced by testing a small sample – often 20 or 30 – of patient records to see if the underlying data supports what the trust is reporting at an aggregated level. 

HSJ analysis has revealed auditors raised concerns about discrepancies between original data and aggregated data in a quarter of trusts in 2017-18. Approximately two thirds of red flags raised related to referral to treatment data and typically concerned conflicting clock start and stop times. In some cases, the inaccuracies may have concealed breaches of the 18 week target. There were similar issues, but in fewer trusts, with accident and emergency data.

Does this matter?

Obviously 20 or 30 mismatched records is neither here nor there in a large trust and the auditors were at pains to point out the error rate could not be extrapolated across a whole trust’s data. And mismatches go in both directions – trusts could be overreporting 18 week and four hour target breaches as well as underreporting them.

But the number of trusts experiencing these problems does say something about the prevalence of data problems in the NHS – and the need to engage with those at the coalface so they understand the importance of coherent data.

With performance on RTT and A&E potentially affected, dodgy data can impact on some of the highest profile measures applied to trusts. And, with provider sustainability funding linked to A&E four hour performance, there could be money at stake as well. There may be good news for trusts if they invest in generating more accurate data, as well as nasty surprises for one or two.