Recovery Watch: The unsexy topic on Barclay’s radar (you’ve been warned)

NHS England published its new Validation Toolkit and Guidance to support trusts last week (file under ‘not sexy but critical’).

The document is the latest in NHSE’s programme to boost validation efforts and follows some new targets being handed out, which, as discussed in Recovery Watch last month are, at best, a little stretching.

The targets, set out in a letter sent to so-called tier 1 and 2 trusts (those with the toughest elective and cancer challenges), as we reported in October, included that, by 24 February, trusts must have validated all pathways which have breached 26 weeks on an referral to treatment pathway.

This will represent a very ambitious challenge for many trusts. But senior trust sources I spoke to said that, regardless of the targets, the guidance comprises a helpful compendium of what is being asked; where responsibilities lie for various aspects; and some good advice and case studies.

The document had to be quite broad in nature because there is a wide range of sophistication across providers, meaning the mandating of standardised processes isn’t appropriate. But it’s well worth a read and many trusts will hopefully be able to learn off those slightly further ahead on the validation journey.

It is also worth pointing out that health and social care secretary Steve Barclay is keeping close tabs on this (so don’t say I didn’t warn you).

Not long after returning to the role after a brief interlude during the Truss premiership, he asked a senior NHSE official: “When can we have a perfectly validated waiting list?”

The senior official in question told a recent NHSE webinar, seen by Recovery Watch, that their response was it would “probably [be] a lifetime’s work”. This was not presumably what the red-tape-busting health secretary wanted to hear.

But it’s reassuring to know that, firstly, this crucial issue is on Mr Barclay’s radar and, secondly, that he should now be under no illusions that while validation is a critical efficiency and patient safety battleground, it is not an easy win.

Spiralling waiting lists mean the existing “business as usual” processes many trusts have been using to validate lists are now simply no longer fit for purpose, and there is so much more work, administrative and clinical, to be done.

And validation, of course, is not just about ensuring the right patients are on the list and seen at the right time. The process underpins how clinical and theatre time is optimised, a major challenge for trusts, especially post covid.

The missing half of the guidance: don’t ‘forget the people (part 2)’

But despite the pros of the guidance and NHSE’s desire to finally grip a thorny nettle allowed to flourish for too long, there appears to be a rather striking hole: the guidance sets out advice on how to take patients off the list who should not be there, but not on finding patients who should be on it.

Leading waiting list expert and HSJ columnist Rob Findlay told me: “The document is right to stress that waiting lists need to be accurate, but then it focuses on checking whether patients on a waiting list need to be there.

“That is important, but not as important as ensuring that patients are not lost in the system. No amount of scrutinising the waiting list will reveal those patients who should be on it but are not.”

It was only last month that NHSE elective recovery national director Sir Jim Mackey admitted that system leaders had “forgotten the people” when it published controversial guidelines in October which said patients faced being removed from the waiting list if they declined two appointment dates.

Like with the infamous “two strikes and you’re out” guidance, it’s critical people do not get overly fixated with making the numbers look better by knocking loads of people off the list and forget that what’s more important is finding those who should be on the list but are not.

Leaders I’ve spoken to at NHSE are only too aware of this trap. But with the ever-increasing political pressure being heaped upon system leaders to improve the optics of NHS performance as much as the reality, it can be easier to focus on easy (well, easier) wins for improving the numbers.

Nuffield Trust deputy director of research Sarah Scobie was also concerned by this apparent hole in the guidance. She warned, too, that the guidance could unintentionally widen health inequalities.

She said: “The guidance appears to put the onus on patients to let services know if they need help with using digital apps or with language.

“There is a risk that you are expecting patients to advocate for themselves in a complex system. Those less able to do so may take even longer to get the care they need, if they do at all. So, this validation exercise could, unintentionally, risk widening health inequalities.

“With routes to care getting increasingly complicated, system leaders need to be mindful about how patients navigate services, especially those in deprived communities and from some ethnic groups.

“The guidance also does not say anything about how to find patients who should be on the list who aren’t there. Again, we know that there are a lot more patients from deprived and certain ethnic minority groups in this cohort, so this could negatively impact health inequalities.”

So, while the guidance represents a laudable first step, perhaps a second edition is required to address how to go about finding the missing patients and ensure health inequalities are not widened by validation? All readers’ suggestions welcome as ever in terms of what form this could take.