Delays blamed on 'varied flows'

Delays for hospital care are the result of inconsistent throughput of patients, not a basic lack of capacity, research by the Modernisation Agency has found.

The agency's director of redesign, Helen Bevan, revealed the new findings at HSJ's redesigning NHS service delivery conference last week.

Analysis of a wide range of NHS activities showed huge variations within the same services.The waiting time for lung cancer treatment at one trust varied from 120 days to less than a week, while in another hospital the number of daily discharges ranged from more than 90 to less than 20. On average, hospital patients who were admitted on a Tuesday stayed two fewer days than those who arrived on a Friday.

'Controllable' elective activity was shown to be much more variable than emergency care, largely because systems were not designed to provide consistency. In one trust, the amount of elective work carried out was five times more variable than in another trust.

The way in which radiologists, for example, processed x-rays could have a very significant impact on how long a patient might wait for diagnosis.

And analysis of ward rounds showed that discharges were more linked to accepted ways of working than the needs of patients.

Professor Bevan told the conference: 'Ninety-nine per cent of delays are not due to the volume of patients. To reduce delays, we need to minimise variability by creating a steady number of patients moving through the system at steady rate. The key focus should be on patient throughput through the system, not resource utilisation.'

The agency director said trusts must get to the situation in which they 'admit the same number of elective patients each day' and produce 'the same mix of expected length of stay'.

She said that although local delivery plans currently being produced by strategic health authorities were full of pleas for greater capacity, this would not be necessary if variations were tackled.

Under analysis: CPWL is cutting times 'by months' The introduction of a new waiting-list system appears to be having a dramatic effect on the variability of service and, therefore, overall waiting times.

The Modernisation Agency has introduced the clinically prioritised waiting-list (CPWL) system in five trusts.The aim of the system is to ensure that routine patients of equal need have equal waiting times according to locally agreed clinical priorities.

The system is based on the theory that if routine patients are seen broadly in turn, maximum waiting times reduce.The essential task is to decide who is a priority and then treat other patients in chronological order.

CPWL involves analysing waiting lists by procedure, specialty and consultant to demonstrate that patients are being seen 'out of order'when compared to the agreed clinical priorities.

Ownership of the lists created by the agreed clinical priorities and greater clarity on who should be treated first smooths out the many variables present in the system which increase overall waiting time.

The system has been trialled since November and is now operating in five trusts.A second wave will begin in April or May and a national roll-out is expected later in the year.Although, the agency stresses that it is too early to determine definitive findings, initial indications are that waiting times have been reduced by 'months'.

Initially, CPWL is being used for surgical specialties, waiting list and booked patients, and in-patient and day case waiting lists.But the agency say it is relevant 'for anything with a queue'.