news in focus

Published: 05/08/2004, Volume II4, No. 5917 Page 12 13

The new 18-week waiting target will see an end to the NHS's 'hidden waits' says the DoH.

But what is driving this target and how can it be measured, asks Lyn Whitfield in the ongoing series on the four public service agreements

NHS targets often seem clear but turn out to have escape clauses.

Think of the 'hello nurse' ploy used to get round the patient's charter requirement for almost immediate triage in accident and emergency departments.

And think of the GPs who have abolished advance booking so they cannot fail the 48-hour access target.

On the face of it, the 18-week waiting-time target set out in the Treasury's public sector agreements, as well as in the NHS improvement plan, has many ambiguities.

The PSA form demands that 'by 2008 nobody waits more than 18 weeks from GP referral to hospital treatment'. But what is a referral, and what is hospital treatment? Does it include outpatient appointments because, after all, only 12 per cent of outpatients go on to become inpatients.

The Department of Health insists the aim is clear. 'It is essentially saying there will be no hidden waits, ' says a spokesperson. 'It is [measuring] from the moment you deal with the NHS to having an operation.'

King's Fund chief economist Professor John Appleby argues that if that is the target, it is not clear how the DoH will measure progress against it.

'We have a general measure of how many people are waiting, we have a census-type count of inpatients and outpatients and we have hospital episode statistics that tell us how long they waited, ' he says.

'We do not have a system to track Mr Bloggs and say he has been to outpatients but has been waiting 10 weeks to get into hospital.'

The National Audit Office urged the DoH to move towards such a system in 2001, when it published its report on Inpatient and Outpatient Waiting in the NHS.

The DoH's response at the time was that 'focusing effort on achieving maximum waiting times for individual stages of care (inpatients and outpatients) is more appropriate.'

That, it added, was why the NHS plan 'outlined an eventual objective of reducing the maximum wait for any stage of treatment to three months'. It also pointed out there would be 'a major difficulty in specifying a maximum because the range of services that patients receive varies greatly'.

So why the change? One reason must be politics.The Conservatives have repeatedly claimed that however well Labour may be doing on inpatient waits, the 'waiting list for the waiting list'has grown.With an election campaign in the offing, the 18-week surgery-door-toknife target neutralises that claim.

Another reason, though, is that there is a feeling within the DoH that while the target is hard it is do-able, which would not have been the case even two years ago.

The NAO report points out that the total time patients wait is generally composed of three elements: waiting for an outpatient appointment, waiting for tests and diagnostic procedures, and waiting for an ordinary admission or day-case treatment.

The element that has received most attention is the inpatient list, not least because the realities of British politics have kept these waits in the headlines for well over a decade.

Waiting lists and times rose in the year after Labour was elected, but have since fallen steadily.NHS chief executive Sir Nigel Crisp predicted in his annual report this year that the NHS might hit next year's six-month target early.

At the same time, average waits are at last starting to fall. In 1997, the median waiting time was 13 weeks. This rose to 14 weeks in 1998, fell to 13 weeks for three years, and then fell to 12 weeks in 2003. It is now just over 10 weeks.

Professor Appleby says this is important because it suggests that most patients - perhaps as many as 70 per cent - are already treated within the 18-week target.

The big question is whether it can be sustained. Professor Appleby has been conducting research into trusts with good, medium and poor records on waiting, and says it shows there is no 'magic bullet' for getting waits down.

He says 'fantastic' pressure on managers and clinicians to meet targets, extra resources, paying attention to patient flows and pinch points - 'the whole modernisation agenda' - and detailed changes, such as moving from individual consultant lists to centralised lists, have all played a part.

However, he wonders whether, even now, the NHS really understands enough about its business to sustain the changes.

'Historically, we have seen really quite big falls in waiting lists and times only for them to creep back up again, ' he says.

Professor Appleby also feels that consultant attitudes are key.

His new research asked consultants to estimate an 'acceptable' wait. Those at trusts with long waits tended to give longer timespans than those at trusts with short waits.

'We need consultants to internalise the targets, to see short waits as part of good patient care, rather than as something thought up by idiot politicians and managers, ' he suggests.

In its 2001 report, the NAO pointed out that less is known about outpatient waits than inpatient waits. The DoH publishes data about patients who have been referred by their GP and who are waiting for their first outpatient appointment. This does not capture how long people have to wait for a second appointment or to be referred on to another consultant.

However, the NAO estimates that second and subsequent appointments make up 72 per cent of outpatient attendances - and these would, presumably, have to be fitted in within the new 18-week timeframe.

Modernisation Agency director of service improvement Michael Scott considers that this year's target - a maximum 17 weeks' waiting time for a first outpatients appointment - has been achieved, since the NHS missed by a couple of thousand patients at most out of the 15 million it sees in outpatients each year.

He also says it is 'on track' to meet next year's 13-week target since the vast majority of patients already reach outpatients in less time than that.

However, Mr Scott believes the 18-week total target is 'a different order of magnitude; a different task'. He says it is one that requires a complete shift, with its focus on outpatients, diagnostics and inpatients.

'My belief is that we will address this [the new target] in two ways, ' he says. 'The first is more capacity:

more nurses, more doctors, more scanners. The other is redesign.

'And when we look at redesign, we see it does not make sense to split up the targets like this. You might well want a one-stop shop, for example, where you get people in and do all their scans and tests on that day.'

Even better, he says, GPs with special interests, nurse practitioners and even telephone services can all stop people coming into outpatients in the first place - especially for follow-up appointments.

This still leaves the third element of the patient journey: diagnostics.And there is a general consensus that this is where the real problems lie.

Even the DoH seems to have little more than anecdotal evidence about what people wait for and how long they wait, although there do seem to be long waits in some parts of the country, particularly for CT and MRI scans.

These may be eased by the fiveyear contract with private provider Alliance Medical to deliver 130,000 scans a year with 12 mobile scanners. The company says this represents a 16 per cent increase in MRI scanning capacity for the NHS.

However, Dr Richard Seymour, one of the Modernisation Agency's national clinical leads for radiology, also says the real key will be service change and more investment.

'There are long waits - perhaps hidden waits - that politicians have previously shied away from because this is such a huge thing to tackle, ' he says.

'I think it is a good thing [that this target has been set], because people will start addressing it.

'I think there are two agendas.

One is the Modernisation Agency agenda, changing the way things work. The other is investment, because if [scanners etc] are going to be used for more hours a day, we will need more staff as well as new ways of working.'

Mr Seymour is also a consultant radiologist at Devon Partnership trust, which reduced waiting times for plan film (x-rays) dramatically by introducing a call centre to match patients with slots at a number of local hospitals.

NHS Confederation policy director Nigel Edwards says the 18-week deadline could be the sort of 'stretching' target that really makes people change their services - 'if it doesn't make them hold up their hands in horror'.

'Some people will wonder what the problem is, some will think this is just undo-able, ' he says.

'And of course, they could both be right, locally.

'That is the thing with national targets; they smooth over local variation.'