London Eye: Leaked data shows waiting list ‘tipping into disaster’

We’ll call you

Consider the London borough of Bromley.

The poshest part of south east London and where the suburbs meld gradually into the Kent commuter belt. This prosperous berg is home to Princess Royal University Hospital, an interesting case study on governance and patient safety.

The latest census data gives the borough a population of 332,000 people.

Why bang on about Bromley, just one of the capital’s 33 local authorities?

Because it’s the closest population in London to the number of patients on the elective waiting list without a decision to admit or a first appointment booked.

A whole borough’s worth of people that the capital’s health system currently has no plan for. A big borough too, the entire populations of Hammersmith & Fulham and Kensington Chelsea come to about the same amount.

As of last week about 4 per cent of the whole population of London have a referral and no appointment.

A regional director’s office document leaked to HSJ makes clear these are outpatients and people on the most urgent pathways, for surgery and similar, are of course being prioritised.

The second wave of covid is predicted to be less intense – fewer deaths – than the first, but is starting to see procedures cancelled elsewhere in the country just as the elective wait position starts to tip into disaster territory.

Of the 10,500 approximate patients already waiting more than a year for an outpatient appointment, only 30 per cent of them actually have a date for their procedure (A ‘to come in’ card), according to the information seen by London Eye.

South east London is the worst performing on this measure, the number of those waiting without a plan.

Only 3 per cent of Guy’s and St Thomas’ patients had an appointment booked, only 10 per cent of those at King’s College Hospital (which runs Bromley’s Princess Royal) have a date.

Yes, it’s a fair bit smaller but props to the Homerton whose performance on this measure is 100 per cent (you have to hope that, whatever form integrated care systems mutate into, any amalgam sees BHR hospitals and Barts become more like the Homerton and not the other way around).

Eyes, teeth

It would be a pretty terrible legacy for the capital if the coronavirus pandemic saw people go avoidably blind.

But ophthalmology is the second most challenged specialty in London, two-thirds of the 57,000 people on the outpatient waiting list had no appointment or TCI, according to the data seen by HSJ.

Ophthalmology was always one of the country’s most backed-up specialties (mysteriously it is also a mainstay in the diet of England’s private hospitals) and the royal college warned about this three years ago. Governance in ophthalmology departments can also be tricky, for example at King’s.

The most challenged specialism in London though is oral surgery, with three quarters of the 18,000 outpatient waiting list currently sat with no date.

Restrictions on oral surgery in covid times are easier to understand than in ophthalmology, but it still an awful lot of people who might be in significant pain.

To be fair, it can be kinder to leave people without a date, rather than give them one and have to cancel because the coronavirus cases have spiked. Although this really applies to surgery more than outpatients (which can be surgery but mostly isn’t).

But hang on, surely ophthalmology was one of the six high volume specialties that were all going to be allocated their own dedicated covid-secure centre, one per ICS in London, to blast through the waiting lists?

Due to be announced at the beginning of September but delayed, at the beginning of October the regional director’s office announced 14 of the promised 30 sites.

Three ICSs had a cataract centre, south east London did not have a named one and north west London seemed to have zero designated surgical hubs.

It’s important to remember there’s actually no such thing as a completely covid-secure site, hence the reluctance to announce them.

Most of the hospitals that had their A&Es closed to reduce the demand for A&Es, sorry, because of the impossibility of staffing them (Queen Mary’s, Sidcup, or Central Middlesex in Park Royal) had an urgent care centre left there so that ministers could say “urgent care is still available at the site, please don’t vote me out” – but in many cases that means they are not actually the kind of sealed elective environment where everyone had been tested 48-72 hours in advance that clinicians would like.

You call us

This new data is all for outpatients but it’s important to remember a lot of pretty consequential things happen in outpatients. It’s where quite a lot of cancers are picked up (London was the region with the most worrying fall-off in urgent referrals for suspected lung cancer).

It also includes cardiology, which is high risk, and one of the areas the London outpatients review team hopes to have a plan for by mid-November. Cardiology outpatient first appointments are currently running at two-thirds of last year’s volumes, dangerous.

There is also a London Patient-Initiated Follow-Up project. Sir Simon Stevens said in less viral times that the current outpatients model was “obsolete”. Doubtless there are lots of pointless follow-ups.

And who could be against “giving patients greater control over their hospital follow-up care?” It’s just the model where the patient has to get in touch if they feel they need a follow-up could miss people off who actually need help. Especially at a time when we’re supposed to be reassuring people that hospitals are open for business. Might make a dent in those waiting times figures though.

Wait watchers

The latest official data, from August, gave the national 52-week waiter total as 111,000, with London forming 19,000 of this.

London Eye understands the capital’s position is now closer to 27,000. And that figure is without the data from large hospital trust, The Royal Free, whose data is in too poor shape to be officially reported.

If this is correct it means the push to “eliminate” 52-week plus waiters (the regional director’s stated but un-deadlined target) is going in the wrong direction.

The August data showed 18,000 people in the 46-52 bracket, i.e. who were at risk of going over a year unless treated between 1 September and now.

The extra 8,000, 52 plus weeks we have now suggests only 10,000 of these people could be treated. And after the most urgent cases are prioritised, 52-week plus waiters are supposed to be the priority, so its hard to imagine the capital’s constricted capacity doing much for people waiting a mere 40 weeks.

The outer London private hospitals are going to be especially important in keeping services going as winter bites.

London Eye understands the deal struck with the private sector is that the NHS can basically run those hospitals, but one third of it must be ring-fenced for private work.

It could start to look quite inequitable if richer people get treated before people waiting longer than a year.

The August figures showed 685,115 people on waiting lists at London hospitals (not including the Royal Free who don’t have a handle on their data) – that’s roughly the population of the boroughs of Camden, Islington with the Royal Borough of Kingston thrown in.

Update on 14.51 at 27/10

A spokesman for GSTT said the data from the London regional director’s office for the trust and King’s was incorrect but could not provide a different figure for the same period.

He said he did not know what accounted for the difference but provided a figure for October 23 that showed roughly 45 per cent of GSTT patients and 35 per cent of KCH patients waiting more than a year had a booked appointment.