From planner to manager, Matthew Kershaw finds himself with the challenge of delivering the care pathway he helped to develop

When I worked at the Department of Health, beginning a project always felt like the start of an exciting journey, with the prospect of benefits for patients at the end. Thinking through the delivery plan for the 18-week referral to hospital treatment target felt as if this could be the greatest journey yet.

The challenge is to bring fundamental change to the experience of patients waiting for elective treatment by asking for fundamental change from organisations that will deliver it. Almost two years later and back in the thick of operational management, I am trying to deliver the 18-week patient pathway I helped to develop.

The policy development was supported by intensive analysis, but there is nothing like being on the front line to achieve clarity.

In my national role I knew that engaging the NHS in understanding the 18-week patient pathway target would be a crucial part of a successful project. I still believe this, but achieving it on the ground is much more of a challenge than it seemed from the DoH's headquarters at Richmond House.

There is unquestionable enthusiasm across the system for improvement and innovation, but there is not universal support for or comprehension of what we have to do to deliver the 18-week pathway. The biggest obstacle is helping the wider NHS to understand the scale of the challenge it faces and ensuring it is prioritised appropriately.

Showing promise

In East Kent, we have the benefit of being a pioneer and have focused work on five clinical areas that already had strong clinical and managerial leadership. We have now reached the stage where early work is showing promise and we need to spread more information about what we are doing - and what can be achieved - beyond the initial group of enthusiasts and converts.

We will be using the views and experience of those involved from across the health economy to do so, but the challenge is great.

We must find ways of reaching out to other health professionals to help them identify hidden waits and seek their support in raising awareness among staff.

One of the key messages for this work was originally: 'If you can't measure it, you can't deliver it.' This remains the case, but it is easy to underestimate the difficulty inherent in counting a whole patient pathway. This is demonstrated by the experience of those now trying to collect, check and report the entire patient pathway rather than each stage of treatment.

Managers and clinicians need to devote a considerable amount of time to this task, and even the use of simple clinic outcome sheets to monitor clock starts and stops is fraught with challenges. A fully developed IT solution is not the answer in the short term. While work is taking place on this, local health economies need to implement a system that provides the data for operational use. I strongly subscribed to measurement as a priority while I was at the DoH, but as I try to implement this its importance as a cornerstone in improving healthcare becomes clearer every day.

However, while engagment and measurement are crucial, we will not deliver the target if we do not also transform the way we work: easy to say and much more difficult to do.

In East Kent, the focus on measurement means that we are only now, a good six months in, finding it possible to focus on the detail of the changes that we need to make. Despite this, there are already some promising early signs of progress. For example, in our echocardiography service, waits have fallen from months to a few weeks without additional resources.

There will be many examples both here and across the rest of the NHS where this type of improvement is possible and we are now developing better methods of identifying and implementing them in order to meet the 2008 timescale.

Unprecedented change

The split between the admitted and non-admitted patients brings a helpful focus as early data suggests there is much more work to do for admitted patients than for their non-admitted counterparts. The reduction in waits for admitted patients will require transformational change the like of which we have not yet seen.

The scale of the challenge in some areas, notably orthopaedics -endoscopy and magnetic resonance imaging - means that service improvement will not be enough. Investment in additional capacity will be required over the next two years. How much we need depends on the results of the initial measurement and the success of service change, but this is emerging at a time when many health systems are under significant financial pressure. The reality, therefore, is that difficult discussions are likely at local delivery planning negotiations between acutes and PCTs.

The need for additional investment is easy to identify and more difficult to secure. It will need to be delivered from April 2007 to prevent the pressure and uncertainty of a 'dive to the line' as the implementation deadline approaches. Patient pathways do not work like that and therefore traditional methods are unlikely to help the project to succeed. The challenge in this and next year's local delivery plans will be to protect the investment for 18 weeks from all the other priorities.

In addition to all the work at local level there is, of course, more work for the DoH, including finalising the principles and definitions, helping in the development of care pathways, highlighting best practice and providing support for those trying to implement the target. This support will be valuable and sometimes essential to achieve target delivery. However, the NHS should not wait for it to arrive.

There is much that can be done now to engage your local system, measure current performance, agree a trajectory, implement service change and agree investment that does not require prescriptions from the DoH. Improved clarity over the fine detail of some of the definitions and details will be invaluable as we get closer to 2008. But speaking as a frontline NHS manager and not a DoH policy maker, I believe that the time to act is already here.

Matthew Kershaw is director of operations at East Kent Hospitals trust.