When the 18 weeks target was announced in 2004 there was widespread scepticism that the NHS could ever deliver it. But in just four years patients are now getting treatment for both admitted and non-admitted pathways in this time – and the median wait is just eight weeks for admitted pathways and four weeks for non-admitted.
"It is a stunning achievement that the NHS should feel proud of," says Philippa Robinson, national implementation director.
From the start it was clear that this was not just another waiting list initiative but would require a transformation in the way the NHS works, with all parts of the patient pathway examined and redesigned where necessary. Patients who would have had to make multiple visits to hospital are now often seen at a "one stop shop" with diagnostic tests often completed at the same time.
Crucially, local health communities have needed to work together to achieve this, says Ms Robinson. Engagement of all those involved in the patient pathway, from the GP to the operating consultant, has been vital.
Bournemouth case study
With a large orthopaedic department and strong focus on elective work, the Royal Bournemouth and Christchurch Hospitals foundation trust had a challenge on its hands to reduce referral to treatment times to 18 weeks.
But not only was this achieved months ahead of schedule, the trust has gone further and is well on the way to reducing waits to 13 weeks.
Scarcely a department in the trust has not played a part in this – from diagnostics through to human resources. But the emphasis has been not just on reducing waiting times but on redesigning how services deliver care.
"We got agreement very early on around additional capacity and redesign priorities," says Richard Renaut, director of service development at the trust. "Early recognition that a little bit of tweaking would not get us through was important. We knew we had to be pretty radical."
Staff involvement was also crucial – the changes were so large they could not be "top down," although leadership from the chief executive and clinical directors was important to create the environment for staff to innovate.
Improved utilisation of theatre time and increased capacity in scanning was achieved through a range of actions including skill mix changes. Good data collection and validation was also important as was increased capacity for elective work, achieved by buying a local private unit and turning it into a dedicated hip and knee trust.
Mr Renaut says the role of the PCT has been critical, firstly in agreeing funding plans and supporting redesign as well as whole system working including GP-led pre-assessment.
"We are reaching 13 weeks in most specialties, and this has given us the headroom to innovate more and make 18 weeks fully sustained,” says Mr Renaut.
But the trust is now finding that the appointments are sometimes too quick for patients – and they are turning down the first available appointment because they need extra time to organise the rest of their lives.
"We are hitting that level where waits are not a complaint any longer – it has gone beyond that," says Mr Renaut.
WWL case study
As a specialist orthopaedic hospital Wrightington in Lancashire faced a particular challenge in meeting 18 weeks – orthopaedics is a high volume specialty with historically long waits.
The 18 week target has been achieved by joint working between Wrightington and its surgeons, and Ashton, Leigh and Wigan PCT, its main commissioner.
Initially patients referred by GPs are now assessed by an enhanced clinical assessment service which incorporates some diagnostics and has consultant input.
This reduced referrals going onto the trust by 20 per cent as more patients are offered appropriate treatment – such as physiotherapy – without having to enter the hospital stream. Investment in diagnostic services has reduced the wait for diagnostics to six weeks and most radiology waits are now just two weeks.
This has also helped to free up consultant time at the hospital to treat the patients who do need surgery. At the same time the trust has expanded its capacity, increasing the number of theatres from four to eight but without adding extra beds – a shorter length of stay has meant the hospital can cope with more patients with the same number. Although the number of patients referred by ALW has dropped, other PCTs are making increasing use of the hospital and the number of consultants has been increased. Consultant orthopaedic surgeon Peter Kay says a recent new patient clinic included patients from Carlisle, Tyne and Wear and Lincolnshire: a sign of the hospital’s national reputation.
Redesign of the patient pathway has also helped: patients are now likely to have diagnostic tests on the same day as they see their consultant as an outpatient, rather than being called back. This one stop shop has reduced the patient pathway, says Mr Kay, with patients being put onto an operating list by the end of the visit.
"There’s nothing like looking at a service to help solve it," says Paul Carroll, assistant director of commissioning at the PCT. "Just paying attention really helps – the weeding out of patients who should not be on the waiting list, asking whether patients are really ready to have the surgery.
"I think one of the challenges for us in the wider NHS sense is for patients and their GPs to understand how quickly they will be seen. I think people still think they will be waiting for an awfully long time."
But Mr Kay says demographics mean the demand for orthopaedic work is likely to increase and reducing wait times may reveal unmet need; "While we might think that we have enough services in place today, we may not have next week."