Recovery Watch: Fresh challenges in counting and cleaning the waiting list

The surprise disclosure last week by Sir Jim Mackey that NHS England estimates there are 5.5 million people on elective referral to treatment waiting lists, rather than the 7 million widely reported, raises several interesting questions.

The NHSE chief elective recovery adviser announced the eye-catching figure during his address at the King’s Fund annual conference last Tuesday.

It is not the first time a figure for individual patients rather than incomplete RTT pathways on the list has been made public. An earlier version of this figure was included in a National Audit Office report published last year, for example. But it is a distinction which is rarely scrutinised.

Sir Jim also revealed NHSE was launching a piece of work to better understand how many people were on the list and who they are.

At this stage, a lay member of the public would have every right to feel confused by these comments. The number of people on the waiting list is announced every month in the official figures, isn’t it (albeit it with a couple of months delay)?

This incorrect perception is perpetuated by NHSE itself, the media (including HSJ, guilty as charged) and the various commentators, who will opine on reports that “the waiting list has hit 7 million” etc.

So, the first interesting question Sir Jim’s comments prompted is: should the NHS communicate, and the media report, the figures in a different way, to make the distinction clearer?

This is an issue I’m afraid I haven’t managed to come to a definitive position on yet. So, if you have any thoughts on this, please do outline them in the comments section below.

A distraction from the real problems

Of course, NHS insiders know the 7 million figure refers to the number of incomplete patient pathways, and the differentiation with actual headcount is because (1) some patients require multiple procedures, and (2) data errors.

So, why does Sir Jim think the actual headcount is somewhere around 5.5 million? I understand the estimate is derived from NHSE’s internal data which shows there are around 5.5 million NHS numbers on the referral to treatment patient tracking list.

There will inevitably be some data quality errors, but this seems as good as possible a ‘finger in the air’ estimate for now (presumably, more granular data will come from NHSE’s deep dive).

Why NHSE has decided to highlighted this issue is also a pertinent question. The sceptic in me – and I am far from alone – suspects the reason why this issue has been thrust into the light now, is that it makes it sound like the waiting list is not as long as it appears, at a time when there is intense, legitimate scrutiny of it.

But, as leading waiting list analyst Rob Findlay told me, this apparent reduction is unlikely to be of much concern to patients. “The vast majority of patients are not concerned about whether there are 5.5 or 7 million other people on the list. They’re worried about how long they will have to wait to receive their care,” he said.

“So, the debate around how many people are on the list feels like a bit of a distraction from the real problems the system is facing right now: that waiting lists, whether measuring units of activity or people, are long and getting longer and so are waiting times for patients.”

Then there are potential operational implications. Another waiting list expert Barry Mulholland argues that while the RTT monthly data was a record of pathways rather than people, “if a single patient needs six different things, then it’s still six units of activity and often multiple different parts of NHS capacity are required, be that surgeons, theatres etc”.

“It’s important not to misunderstand that reporting pathways represents capacity needed whereas reporting it by patient numbers does not,” he added.

Cleaning up the data

One logistical task related to this piece of work which Mr Mulholland, a partner at MBI Healthcare Technologies, did agree needed addressing, with significant logistical implications for trusts, was a major validation exercise to clean up the duplicates and other data quality errors on waiting lists.

This is an issue NHSE has been trying to get a grip on for some time. But Mr Mullholland raised concerns about the latest set of targets system leaders have set the most challenged trusts in terms of validating their lists.

The targets were included in a letter sent to so-called tier 1 and 2 trusts (those with the toughest elective challenges), as we reported last month.

The letter sets out a series of deadlines for waiting list validation, including that, by 24 February, trusts must have validated all pathways which have breached 26 weeks on an RTT pathway.

Mr Mulholland said: “[The February target] is, at best, a massive challenge. This means trusts are being asked to validate, on average, up to 30 per cent of their entire PTLs, by February. That’s a very big ask and few trusts will be able to achieve this.”

“Validation really should have been done during the covid lockdown, but unfortunately, many trusts didn’t take this window of opportunity to clean their lists.”

Recovery Watch will be keeping tabs on NHSE’s project on getting a better grip on the actual headcount on the waiting list and what it means for the NHS operationally. But it is highly unlikely the differential in the figures will have any meaningful impact on how patients view their long waits for planned care.