NHS England’s priorities point to a patient safety approach on waiting times. But will the government override them in pursuit of targets?

The NHS has supposedly been given £1bn to tackle referral to treatment waiting times, though after NHS England’s higher priorities have been paid for (dealing with deficits, emergencies, cancer, mental health and primary care) there may not be much of it left.

Nevertheless, NHS England’s principles are surely the right ones: put clinical priority patients first, and then do what we can for the routines.

But those principles are under threat. To see why, we need to examine how the RTT money could be spent.

Safety first

The principled approach to RTT waiting times would maximise patient safety.

Most importantly, this means short waiting times for first outpatient appointments. Remember that only a minority of cancers are referred on a two week pathway – we need to see all new outpatients quickly to find out what’s wrong with them.

Next, making sure patients who attend regularly do not have their appointments put off. People are going blind because their macular degeneration or glaucoma checks are being delayed to make way for RTT patients – even though they are clinical priorities and should therefore take precedence over routine conditions.

Finally, treating the very longest waiting patients. It makes little difference, from a clinical safety point of view, whether the typical RTT waiting time is 18 or 22 weeks. It is the extremes that matter, so existing and extra resources need to be focused on the patients who are waiting the very longest.

Happy doctors, unhappy spin doctors

That all sounds great – but we need to recognise that a safety led approach will not have much impact on the waiting time statistics.

Many patients are discharged following their first outpatient appointment. If first outpatient waiting times are kept short, lots of patients will be discharged after only a short wait. That reduces the number of short waiting patients on the waiting list without much affecting the number of long waiters, so the headline performance – usually (but unwisely) measured as the percentage within 18 weeks – will be worse.

Regular attenders are not covered by the RTT targets at all, so devoting capacity to them leaves less capacity to improve RTT performance.

And what about the very longest waiters? Clearly, treating them does improve RTT performance because it reduces the number of over 18 week waiters without affecting the number of short waiters. However, these patients have ultra-long waits for a reason: it is difficult to find the capacity to treat them and they tend to be expensive. Focusing on them means treating fewer patients.

Managing to the target

If, on the other hand, your concern was simply to make the numbers look good, you could take a completely different approach: minimise the number of over 18 week waiters and maximise the number of under 18 week waiters. That achieves the highest possible percentage within 18 weeks when all specialties are added together and is an approach that many local services already use.

It’s a simple approach. Want to minimise the over 18 week waiters? Treat the cheapest and easiest ones, in outpatient dominated medical specialties, and day case dominated surgery such as ophthalmology.

Want to maximise the under 18 week waiters? Let waiting lists grow so that all routine patients are forced to wait nearly 18 weeks (and consider imposing minimum waiting times). In particular increase the waiting times for first outpatient appointments so that fewer patients are discharged after only a short wait.

Although this approach would produce attractive RTT statistics, it also means timely access to NHS services would depend not on clinical need but on the NHS’s ability to pay.

If you needed something expensive like a hip replacement, you’d be kept waiting with only vague promises of treatment. Unsuspected cancers would be detected too late because of long delays in outpatients. And patients would continue to go blind as their regular appointments were put back.

This is the harm that waiting time standards were supposed to prevent.

What will the government do?

Whether it is pushed out centrally or awarded bid by bid, the centre will have to decide which approach to follow when allocating the extra RTT money.

NHS England has already laid out its priorities and they point clearly towards the patient safety approach. The only way “managing to the target” could prevail is if the government (via the health secretary) were to insist on it in next year’s NHS mandate.

Jeremy Hunt, has been a staunch champion of safety and quality and it would be peculiar if he were to place himself in opposition to patient safety by insisting the targets should be met regardless of the consequences. Nevertheless, the early indications are that this is precisely the line he is taking.

In tough times like these that people’s values are really tested. As the mandate takes shape, we will find out how sincere the government really is when it comes to patient safety.

Rob Findlay is a specialist in demand and capacity planning, and director of the software company Gooroo Ltd.