Published: 05/12/2002, Volume112 No. 5834 Page 24 25
The Department of Health claims that the service is making 'solid progress' and is 'on course' on waiting-time targets. But is the centralised enforcement of steady reductions in maximum waiting-time guarantees wrong-headed? John Yates reports The September waiting-time results were announced under the headline, 'Solid progress on reducing 12-month waits' and waiting-time reductions were described as 'on course'. The optimistic focus remains fixed on this year's targets, but the basis of that optimism is difficult to understand. In the first half of this year, waits over one year fell by about 6,000, leaving the second half of the year to remove over 16,000 patients from the lists, despite the long Christmas break and any winter pressures that might occur. In fairness, for the NHS that is 'on course'.
It is when looking at the longer-term targets for 2005 that we need to examine the impact of current policies. For outpatients the policies appear to be working, although the number of GP referrals not seen who wait over 13 weeks for a consultant appointment has increased for two successive quarters. However, as a result of the spectacular drop in March this year, the NHS is still on track to deliver the required reduction to nil by 2005 (see figure 1).
More worrying is the continued slight increase in the number of inpatients and day cases waiting over six months (see figure 2). In December 2000, following the publication of the NHS plan, there were 267,127 inpatients and day cases waiting over six months for admission. In order to meet the 2005 deadline over the following 20 quarters, the NHS needed to reduce the long-wait patients by an average of 13,356 a quarter. In the first seven quarters it has averaged a reduction of only 1,871, leaving the remaining 13 quarters to be reduced at a rate of 19,541 per quarter. Very few quarters have seen reductions in excess of that level, although in 1998-99 there were three consecutive quarters in whom the list fell by over 32,000. How that was achieved is uncertain, but it was in this period that the NHS was said to have treated large numbers of minor cases in order to help bring the total waiting-list size in line with the government's election pledge.
One wonders just how long it will be before current policies have a real influence on inpatient waiting times or at what point they may need to be modified.
As in most other countries it is common to see several policies adopted simultaneously, partly because the complex problem requires more than one solution and partly in panic by throwing everything available at the problem. Current strategies include buying more operations in order to reduce the backlog (in both state and private hospitals), sending patients abroad, introducing booking systems, renegotiating consultant contracts, introducing consumer choice, producing comparative information and making maximum waiting-time guarantees.
A key element of the strategy in England remains the enforcement of steadily reducing maximum waiting-time guarantees. It is a strategy that causes conflict when clinicians object to the dogmatic insistence that there are no exceptions to the chosen rule (eg no patient waiting over 15 months), even when clinical priorities are badly distorted. It is for that reason that some European countries have abandoned the policy and why others have modified the target by suggesting that no more than (say) 5-10 per cent of patients should fail to meet the target. There is surely a case for modifying the English policy.
More fundamentally, one wonders why we have ignored one of the few proven methods of reducing numbers of long-wait patients.
The method, first used in England in 1989, is to negotiate a contract between the government and individual hospitals that guarantees additional workload and reduced waiting times. The contract negotiation includes the following stages:
Agree a baseline workload, based on activity over the past three to four years;
n Compare the baseline with the levels of activity that are achieved with normally staffed and reasonably competent hospitals;
Choose a method of obtaining extra workload that will reach or exceed the expected standards;
Agree the level of expenditure required (and pay in advance);
Define monthly workload and waiting-list reduction targets.
Once contracts are established the monitoring process has three elements:
Share information on a monthly basis (within 14 days of month end);
Terminate the contract if it becomes clear it will not be achieved;
Claw back revenue on a pro-rata basis to any failure in the contract.
In 1989-90 this method was used over a 15-month period to tackle England's 100 largest waiting lists.
They constituted 22 per cent of England's total waiting list and 39 per cent of the long-wait (over a year) patients. The result was a 43 per cent reduction in long-wait patients, a 12 per cent increase in admissions (in 12 months) and no overall increase in outpatient waiting times. Elsewhere in England where other policies were being tried, the reduction in longwait patients was only 12 per cent. On 8 May 1991, the health select committee concluded that the progress made in reducing the numbers of long-wait patients using this method 'has been greatly superior to the progress made by regions and districts on their own'. The same method has been used in Spain by the national institute of health, which was responsible for managing hospitals for about 35 per cent of the population. Between 1996 and 2000 the average (mean) waiting times fell from 210 days to 67 days.
One problem with the method is that it is seen as too 'centralist' and runs contrary to the theme of delegated responsibility. The contract negotiation and requisite monitoring process brings together civil servants, clinicians and managers in a way that bypasses all other tiers in the organisation. Even though it is good for patients it does not suit the organisational structure or the ideologies of NHS management. The great advantage of this policy is that even if it fails - and it hasn't yet - you get your money back. l Professor John Yates is director of inter-authority comparisons and consultancy at Birmingham University's health services management centre.