Early learners

While many health service managers are already sweating about the chances of achieving the December 2008 target for referral to treatment times, a select few should be reaching for the extra-strong anti-perspirant.

They have committed to delivering 18 weeks for a minimum of 90 per cent of admitted patient pathways and 95 per cent of non-admitted patient pathways by December this year, 12 months before the rest of the country has to hit the 18-week target.

One manager admits: 'Everyone thinks we are a little bit mad.'

But what makes these hospitals and primary care trusts convinced they can get there? And are they representative of the NHS as whole?

The 13 early achiever sites come disproportionately from the NHS North West area (five sites) and NHS West Midlands (four sites). While there is a scattering of sites from other strategic health authority areas, there are none from London or the East of England.

One area - East Kent - was among eight 'pioneer' health communities that have spent the past year looking at how to measure the time patients wait from referral to treatment, and then how to reduce this.

This has put the trust ahead of the pack, as understanding how long patients wait and why is seen as crucial to achieving 18 weeks.

'If you can't measure this, you can't achieve it. You need to understand what the drivers are,' says Matthew Kershaw, chief operating officer at East Kent Hospitals trust and one of the architects of the 18-week target during his time at the Department of Health. 'There can be differences even within the same specialism.' He says that admitted patients are easier to count, but more difficult to deliver 18 weeks on, while non-admitted pathways are more difficult to count but usually easier to deliver on.

Other sites freely admit they suffer from all the same data issues as the NHS as a whole. At Doncaster and Bassetlaw Hospitals foundation trust, director of performance Lynne Rothwell says the information available is 'pretty ropey' and the figures for 18-week achievement could be 10 or 20 per cent adrift of the true picture. The trust is at 46.4 per cent for admitted patients and 69.7 per cent for non-admitted patients - although there are significant variations between specialties.

'We have a major project around tracking patient activity, allowing us to track them through their journey and flag up where they are,' she says.

Across the country the same areas come up as potential issues for the early achievers: orthopaedics (with typically longish waiting times made more of a challenge by the number of patients involved), odd areas of diagnostics such as audiology and endoscopy, and then some smaller surgical specialties. This is probably common to many trusts and does not mark the early achievers out, although they may have lower waiting times than average. Blackpool, Fylde and Wyre Hospitals trust hit 10-week waits in outpatients and 20 weeks for inpatients in December - several months ahead of the national target. Waits for outpatient appointments in general surgery are down to two weeks and four to five in ear, nose and throat.

In Derby about 40 per cent of patients were treated by 18 weeks against a national average of about 35 per cent. 'We have not got a major advantage. We have a long way to go from 40 per cent,' says Diane Gamble, who is leading on 18 weeks for Derby City primary care trust.

Many of the early achievers have already seen significant reductions in waits for some diagnostic tests. Echocardiography, for example, has gone from six months to four weeks in East Kent through better scheduling.

In Bolton Hospitals trust, a great deal of effort has been put into diagnostics during the past year - with some dramatic results, such as endoscopy waits coming down from 44 weeks to six. The trust has also looked at how it is reducing its waiting times and has reduced average waits rather than just outliers. 'I think we are a bit ahead of the game,' says chief executive David Fillingham. The trust has been adopting lean techniques - similar to those pioneered in the car industry.

Other issues across the country are likely to involve PCT and GP input. For example, dermatology, which has long waits in some areas, could see some work transferred to GPs with special interests, in line with government policy. Good working relationships between PCTs and acute trusts will ease this process. Harry Clarke, associate director for planning and performance at Blackpool, Fylde and Wyre, says the relationships locally have not had the adversarial element that some areas experience.

In Derby, Ms Gamble has had free access to much information from the acute trust. Says Kathryn Blackshaw, director of commissioning and service improvement at the PCT: 'It is fantastic that people don't see this as a competitive process. We might be unique in that.'

Most early achievers also seem to have got to grips with list management and triaging patients in at least some specialties - reducing the number going forward to consultant outpatients by streaming some off to more appropriate care. Blackpool, Fylde and Wyre gets potential surgical patients to fill out a questionnaire as soon as a decision is made, to highlight any who cannot have the operation they are being booked for.

But getting to 18 weeks will be about dealing with emergency work as much as elective, suggests Ms Rothwell. A rush in emergency work can threaten elective work, and delays in getting patients out of hospital will do the same. A new urgent care centre will assist in this - although it may not be up and working in time for the December 2007 target she faces.

Shocks to the system

Achieving 18 weeks will also need to be shock-proof: capable of being supported every day of the year, regardless of winter slips and trips, the odd ward closure due to infections, and staff holidays and illness. Julia Taylor, who leads the 18 weeks programme at the NHS Institute for Innovation and Improvement, points out early achievers will still have another year to iron out glitches.

Many trusts say the level of service transformation they are undertaking should ensure that the 18 weeks target is sustainable. But it may not be so easy in trusts where there are single-handed consultants in some specialties or small diagnostic areas dependent on particular staff. Sudden pressures on emergency care can also lead to issues with beds.

'There is no point in getting to 18 weeks at a point in time and then not being able to sustain it and going off the tracks again,' says Mr Clarke.

Finance may be one of the areas where the early achievers stand out - the PCTs among them are going to have to foot the bill for 18 weeks earlier than other areas, which means areas with chronic financial problems probably did not consider applying. Those selected tend to be in a reasonable financial state - and they will need to be as reaching 18 weeks will mean doing extra
work this coming financial year to clear the backlog of patients and reduce the maximum wait. This is a challenge all PCTs will have to face but the bill will arrive with early achievers sooner than the rest.

At Derby City PCT, for example, there has been no need to push back waiting times to achieve financial balance, as with many PCTs. 'You have to eliminate the backlog of waiters,' says Mr Fillingham. 'The PCT has enough reserves to allow that, partly by getting more work through the hospital and using the independent sector.'

Manchester PCT is not in significant deficit but Tony Ullman, associate director for commissioning and performance improvement, says funding the move to 18 weeks 'will be a financial challenge'. 'In order to achieve 18 weeks we have to invest at some time, whenever we do it. Early achiever status does not cost more but it brings that investment forward.'

If they have shorter than average waits anyhow, it may also mean investment needed to do the extra work this year may not be so huge; the areas that will struggle to find the money will be those with a large backlog of patients.

In East Kent, Mr Kershaw points out that backlog grows each month so the quicker it is tackled, the smaller the task is. But he also asks whether patients' expectations are changing and if there are other factors that will have an effect. For example, will people who would previously have gone private to avoid a long NHS wait now be happy to be treated within the NHS?

South Devon Healthcare foundation trust director of performance and development Sasha Karakusevic suggests the health economies have, to some extent, put themselves in this fortunate position through partnership and good leadership. Becoming an early achiever brings very little money and South Devon does not do especially well out of allocation funding, he says.

However, Mr Clarke points out: 'Not dealing with patients in an effective and efficient manner is wasteful and ends up adding more costs.' In the long-term, there could be savings as unnecessary hospital appointments are eliminated and working practices made more efficient.

Flying with a half-full plane

There are potentially extra costs in running to 18 weeks, as well as savings. Mr Karakusevic highlights the issue of outpatient clinics. To progress patients quickly through the system it will be necessary for them to come in for early outpatient clinics, which may not be full or may be smaller than in the past.

'We are going to have to think carefully about scheduling and working at capacity,' he says. 'We will end up with a problem like the airlines - taking a half-full plane out.'

More generally, hospitals are likely to find it easier to get to 18 weeks if they are not working flat out with 95 per cent-plus bed occupancy (after all, this is how many private hospitals can offer early operation dates - they simply are not full). And there may be benefits for the acute trusts in getting to 18 weeks early - they may become more attractive to patients, who will exercise their choice under choose and book. The danger here is that they attract more patients than they can cope with and this puts pressure on the sustainability of 18 weeks.

Another area where the early achievers may stand out is in clinical engagement with the work needed to achieve 18 weeks. Most have started the process - even if not everyone is signed up yet. At East Kent, clinicians have been working closely on these projects but 'it is less good when it broadens out to all of their colleagues', says Mr Kershaw. 'This appears from a consultant perspective to be much more about what they do each day - managing the patients' journey.'

It is striking how some of the early achievers are already talking about GPs and practice-based commissioners as vital partners. Mr Ullman in Manchester, for example, points to the need for GPs to understand the new pathway. GPs may be expected to 'work up' diagnostic tests before the patient even sees a hospital doctor, so their co-operation will be important.

Many of the other early achievers have obviously good relations between PCTs and acute trusts and are already beginning to work through what achieving 18 weeks will need from all partners. In Derby City PCT's case, staff are thinking about how it will interact with local authorities and starting to talk to them. 'Any hospital that tries to do it in isolation is setting itself up to fail,' points out Mr Karakusevic.

In many cases the decision to apply for early achiever status was taken jointly between PCTs and acute trusts - 18 weeks is technically a PCT target but as the corollary is to not be commissioning from trusts that cannot offer an 18-week pathway, it is acutes that have the big incentive to get there.

Don't leave it all to the PCT

A few seem to see it as just one organisation's responsibility - one referred to the 18-week target as being something the PCT was leading on, as if the acute trust was not involved. In other cases, the thinking on what this will mean for PCTs and individual GPs seems to be in a formative phase.

The health economies of early achievers may also have good leadership and an organisational culture that can help them achieve 18 weeks. These acute trusts and PCTs are not only tackling 18 weeks willingly, but there is also a sense that it is not the end point - it is part of a process of improvement that is continuous and will lead on to other challenges

There is a willingness to embrace change which seems to extend beyond the executives. 'Any organisation that is going to stick its hands up in the air to achieve the 18-week target has got to have strong leadership and support from the top team,' says Ms Taylor at the NHS Institute. 'Good luck to them - it's a challenge.'

Goodbye to unnecessary delays

Capita Advisory Services director of healthcare Neil Griffiths says: 'They are organisations which have stepped up to the mark because they have senior backing to do it and have the discipline in place. They are the organisations with the attributes to get them there.'

For example, an initiative to run all-day orthopaedic operating sessions at Bolton - a move which will increase the number of operations each day from four to five, a 25 per cent increase - is supported by surgeons. Mr Fillingham believes in getting out into the workplace to see what is happening, rather than simply analysing data.

Some of the organisations are already marked out as being high achievers - Derby Hospitals foundation trust, for example, won the maximum three stars each year under the old performance rating system. 'We have a proven track record of reaching our targets,' says David Ainsworth, lead for service improvement. The trust is also going to benefit from the extra capacity provided by a new hospital but will also need to reshape patient pathways, he says.

Mr Karakusevic says: 'We have had a model of what the world is going to look like, which helps,' he says. 'What matters here is a degree of vision, a focus on the whole pathway and looking for sustainable solutions rather than trying to do quick fixes. There is huge enthusiasm and gritty determination to get there.'

He stresses that 18 weeks is less an end in itself and more of a milestone on the way to a 'no unnecessary delay' system of working and thinking.

Ms Rothwell at Doncaster points to organisational culture: 'We are a can-do organisation. We don't fail. It is probably quite a tough place to work because it is demanding, but I think that is what is different.'

She adds an important caveat - even with this attitude, good staff and PCT support, getting to 18 weeks early will be a massive challenge - a view echoed by other early implementers, who accept that, although they may reach the December 2007 targets, it will take longer to embed and consolidate the 18-week wait.

They believe they can get there - a belief that may be lacking in other trusts.

They are also clear about what needs to be done: 'total service transformation' as one manager puts it, rather than tinkering at the edges.

Eighteen weeks will need everyone to think in terms of patient pathways from the time of referral through to discharge - which is often not done now. Doing 'more of the same' - which has historically been the response to long patient waits - won't work. The message for other trusts is clear: they need to start now if they are to hit the December 2008 target.

'The NHS is sleepwalking into it,' says Ms Rothwell. 'Even we were a little bit complacent.'

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