news focus

Published: 30/01/2003, Volume II3, No. 5840 Page 12 13

A mood of quiet confidence is surrounding the 21-week outpatient waiting-time target, which has to be hit in just nine weeks.Paul Stephenson reports 'F rantic rush to March target', was the headline. 'Trusts are facing a desperate struggle to meet the government's commitment to eliminate outpatient waits of over 26 weeks by the end of March.'

HSJ's lead news story a year ago (news, pages 4-5, 28 February) detailed the battle to bring down the numbers of outpatients waiting six months and more.

Numbers had remained static for about nine months, and managers were fearful they would not meet the end-of-year target.

In fact, the NHS missed it. But only just. Five hundred patients were waiting 26 weeks or more when the deadline was reached.

This year, the target for March is tougher still. In less than nine weeks' time, trusts need to hit a milestone of 21 weeks en route to a final goal of a 13-week maximum by 2005. One can only imagine the fevered anticipation of the service now.

So what is it like out there?

Surprisingly, the mood is calm.

NHS Confederation policy director Nigel Edwards says: 'People are quick to mention things to me that are a worry, but that is not one of them.'

Professor John Yates, director of inter-authority comparisons and consultancy at Birmingham University health services management centre, says that although there are serious doubts about inpatient targets, the outpatient ones should be more easily achievable.

He believes this is partly due to the distribution of patients waiting for outpatient appointments being more evenly spaced along the time-line. This means that it is equally easy to get from one target to the next without hitting huge clumps of patients waiting at one particualar time spot. By contrast, in inpatient appointments, moving from 15-month to 12-month maximum waits is likely to be much easier than moving to nine and then six months because of the higher number of patients waiting the shorter time spans.

When it comes to outpatients, some trusts have not only already achieved the 21-week maximum outpatient wait, but already have nobody waiting more than 13 weeks. Others have been making steady progress against the national targets by setting themselves local targets that are beyond the official ones.

Chesterfield and North Derbyshire Royal Hospital trust is well ahead of the game. Chief executive Eric Morton says: 'We have always regarded outpatient waits as pretty sacred and we have always tried as far as possible to see our outpatients in 13 weeks. We got to 13 weeks in March last year.'

Mr Morton says this was achieved by a lot of hard work and co-operation within the local health economy and that good management of the lists was vital: 'We have pretty low levels of did not attends and vacant slots. We are on a booking system and we phone people at home. The booking system squeezes things out of the system.'

Royal Orthopaedic Hospital trust chief executive Christine Miles says the trust, which has received extra money to get waiting times down further than the national targets, has also been helped by a partial booking system. She says that although the trust is hoping to meet the 13-week target by the end of March, there are problems that can be difficult to overcome: 'Some of it is about extra consultant appointments. Some of it is about using a physiotherapist or musculoskeletal specialist.

However, there are particular subspecialties that will have long waits, and it is not as if you can transfer patients to other surgeons.'

In most trusts, the improvements in services have been due to a combination of improved management of lists and altering the running of clinics.

King's Fund chief economist John Appleby points out some things are common to trusts: 'The whole move is to the greater involvement of managers in patient flow through the system.

Managers are having to keep tabs on individual patients. It is about routing the patients correctly as there will be patients who turn up who shouldn't be there.'

The importance of this micromanagement of lists is confirmed by Portsmouth Hospitals trust director of operations Simon Payler: 'There is very careful monitoring and the IT systems for this are quite splendid. It is an ongoing process of reorganising clinics.

What we have got better at is seeing patients in chronological order. After any clinical priorities, it is key to see patients in order.'

However, though the trust is confident of meeting its targets this year, Mr Payler believes it will become harder over the next couple of years: 'At the moment, we are beating the tail [of the waiting-list graph] back, but at some time we will have to climb into the body.'

Essex Rivers Healthcare trust chief executive Mike Pollard also points to better management of patient lists as crucial: 'We have made quite remarkable progress.

The patient priorities treatment list says you divide your outpatients into two categories - the urgent clinical priorities and the routine appointments.'

He believes that routine appointments are then treated in order of how long they have waited and this has been the biggest contribution to improvements.Using staff other than consultants to reduce waiting times has also been important, even in difficult areas such as spinal surgery. At Whittington Hospital trust, the service for patients with back pain has been totally redesigned using a spinal nurse specialist who runs clinics to triage patients suitable for spinal surgery. This has helped reduce waits from over 52 weeks to 26 weeks in 2001-02.Waits are now running at 20 weeks .

The figure was brought down by the use of one spinal nurse specialist working with physiotherapists. Director of operations for surgery, women's and children's health Tara Donnelly said only around 6 per cent of patients with back pain were suitable for surgery, and the nurse specialist assessed the need for surgery and could refer then refer on to physiotherapists or pain clinics.

This type of work comes as no surprise to the Modernisation Agency, which has been advocating a five-step approach to managing outpatient waiting lists.

Agency national programme director of access, booking and choice Matthew Coats says the steps are to benchmark performance against high-level performance, to commission on the basis of need rather than historical patterns, to review the clinic schedules themselves, to review outpatient efficiency and to look at the appointments system.

Though the outlook on outpatient lists is rosier than elsewhere, there are concerns about the impact reducing outpatient waits will have on inpatient lists, the socalled conversion rate from outpatient to surgery. The impact of this is that trusts may find it difficult to meet their individual targets to cut a certain percentage off their list sizes.

Mr Pollard says this is proving to be a problem at his trust: 'The more we pull down the outpatient waiting lists, the more we put onto the inpatient lists.'

The effect, he says, is that 'there will be more people on the waiting list, but waiting less time'.

However, Mr Appleby says evidence from King's Fund research shows that this is not always so.

He says at one trust 'there was a fear that if they started to meet their outpatient targets there would be a wave of [inpatient] work that would hit the consultants, but that didn't happen'.

Mr Coats agrees this should not necessarily be a problem: 'Very high conversion rates might mean you need to talk through with clinical staff the need to work through who those patients are.'