The 13 'early achiever' trusts are on the final straight of the 18-week referral to treatment target, although some have yet to clear the last hurdle. Alison Moore reports on efforts to eliminate waiting list backlogs as the rest of the field looks on

On 31 December a small band of NHS managers may be raising their glasses to the achievement of a key target a year early - 18 weeks from referral to treatment.

While the rest of the NHS views this target with trepidation, 'early achievers' hope to be either treating 90 per cent of admitted patients and 95 per cent of non-admitted patients within 18 weeks, or to be within spitting distance of the target.

The rest of the NHS has another year to get there - although an interim target of 85 per cent admitted and 95 per cent non-admitted by March 2008 is already looming large in managers' minds.

But getting to 18 weeks has not been an easy ride. Some of the 13 sites appointed as early achievers are likely to miss the target, while others are hoping a late push will see them edge past the post. The effort required has been colossal. One implementation lead says: 'I think all the general managers have aged 10 years in the past six months.'

First to hit the target was Yeovil District Hospital foundation trust, which got there in March and has sustained it every month since. Others are near: Taunton and Somerset trust, for example, says at the end of October it was at 79 per cent for admitted patients and more recently at 88 per cent for non-admitted patients.

East Kent Hospitals trust - for which former Department of Health policy pioneer Matthew Kershaw is now chief operating officer - was at 40 per cent for admitted and 70 per cent for non-admitted, according to papers presented at November's board meeting.

However, he says the groundwork has been done to enable a dramatic increase.

In Derby, clearing long waiters has kept the 18-week achievement rate down to 49 per cent for admitted and 77 per cent for non-admitted in October, but it hopes to hit the target in January.

Success has not been universal. A report to Manchester PCT's board in the past few days highlighted Central Manchester/Manchester Children's University Hospitals trust as predicting 79 per cent of admitted patients being treated within 18 weeks by December.

Mr Kershaw says no-one should underestimate the challenge before them. His advice to the rest of the NHS is: 'Don't leave this too late in terms of a drive for the line at the end. It is not like things that the NHS has done before where you can do a lot of work at the end.'

Manual labour

A major challenge for many areas has been getting the data right. Currently NHS systems are not designed to track 'referral to treatment' times or to 'stop the clock' at appropriate times.

Trusts have been working round this, either devising local IT-based solutions or manually adjusting the data. Doncaster and Bassetlaw Hospitals foundation trust director of performance Lynne Rothwell says: 'Our patient administration system does not have a stop-clock function so there has been an awful lot of manual work - and I know that other early achievers have been doing the same.'

Recent trust figures suggested 64 per cent of patients being treated within 18 weeks - but the real picture is far better than that, she claims. Changes due to patient administration systems in the next few months should make the task easier for other trusts aiming for 18 weeks by the end of 2008.

Inevitably, 18 weeks involves a lot of data collection and often a validation exercise to ensure waiting lists are accurate. Data collection also needs to be carefully explained to staff. Harry Clarke, associate director of planning at Blackpool, Fylde and Wyre Hospitals trust, says staff needed to understand 'that we were not just collecting it for the hell of it'.

A key part of 18 weeks is likely to be getting the right patients into the hospital stream and keeping inappropriate referrals out. Referral management centres or clinical assessment and treatment centres may be part of this - but need to deal with patients swiftly to avoid becoming another drag.

Reducing inappropriate referrals is likely to mean fewer patients are seen in outpatients but they are more likely to progress to other treatments. Doncaster needed to look at some consultants' job plans to change the balance between outpatient clinics and time in theatre. This switch to providing more theatre time seems to be a common theme.

Another key to achieving 18 weeks is whole system working. 'We had a very good and robust whole health economic plan,' says Mr Clarke. 'Virtually everyone has been drawn into the 18-week target. People have been very upbeat about what they have delivered to date.'

For some groups it may mean extra demands for flexibility in how they organise their workload over a period of time. Although trusts have been thinking about that, they feel they are only scratching the surface.

Mr Kershaw says moving from thinking about stages of treatment to pathway management has been a profound change.

While some pathways have fitted happily within 18 weeks, others - such as ones where a decision on treatment will only be taken after a long series of diagnostic tests - will leave trusts with a short time to offer treatment and still be compliant. This has implications for capacity management.

Legacy of waiting

Trusts have also had to clear waiting lists of those who were already waiting more than 18 weeks - so-called legacy patients - and this has meant carrying out an extra hump of work this year, which should not reoccur.

'We have done almost 20 per cent more operations than we had in the same period of the previous year,' says Bolton Hospitals trust chief executive David Fillingham. 'Some of that has been through redesign but some of it has been through extra throughput with evening and weekend clinics.'

That has financial implications for PCTs, which will have to find the money for these extra procedures; the early achiever sites have tended to be in parts of the country with fewer financial problems.

In Blackpool, the trust and PCT reached an agreement at the start on what was needed to deliver 18 weeks.

'It has needed some tweaking around the edges but it has held up well,' says Mr Clarke.

At East Kent, extra orthopaedic work had to be bought in the private sector. Unexpectedly, Mr Kershaw found compliance with 18 weeks dipped this autumn as the trust struggled to clear legacy waiters. However, it is recovering.

'We thought we would have a trajectory which rose gently towards the target but in fact the actual numbers have been down a bit,' he says. 'We are managing this now on a daily basis.'

Clearing legacy waiters is necessary but can be dispiriting for staff who see lots of extra work being done but no improvement in the percentage of patients treated within 18 weeks, says Derby PCT director of commissioning and service improvement Kathryn Blackshaw.

'The danger is that we concentrate on all of the problems and don't celebrate the successes,' she says. The city's acute trust has coped with the change programme while also moving into a new hospital.

Other challenges have been around orthopaedics, where many trusts have made use of the private sector or independent sector treatment centres. In some cases, this has meant the cases left at the trust are the more complex ones, requiring more theatre time.

Trusts doing tertiary work face extra pressures as there may be delays before patients enter the trust's system. Blackpool does some specialist cardiac work and this issue has had to be overcome there. Mr Clarke expects the trust as a whole to get to 18 weeks on time but tertiary work to be a few months behind other specialties.

But sometimes delays are in unexpected areas. There has been a lot of emphasis on the time from referral to first outpatient appointment and many organisations are justly proud of the significant reductions they have achieved. But Doncaster found there was often a delay in getting a follow-up appointment and needed to address that.

Fully booked

It also faced dilemmas over choose and book. Patients using this needed to be offered appointments within a fortnight or their progress towards 18 weeks would falter; yet releasing sufficient appointments to ensure this could mean that there was unused capacity.

Ms Rothwell points out that is likely to be a greater issue as the local health economy moves towards a 'no wait' culture - an aspiration of several of the early achievers.

They are aware they will be attractive to other patients under choice - Ms Rothwell says people are definitely choosing on access times - and may be able to offer extra capacity to other health economies moving to 18 weeks.

'We think we are in a strong position to do work for other PCTs that are not yet at 18 weeks,' says Mr Fillingham. 'We should not have to continue at the same rate as we were clearing a backlog. But we know that referrals from other PCTs are going up in some specialties.'

Mr Kershaw believes sustaining 18 weeks will be a different - and as yet unknown - challenge to getting there. 'We are still working through the first quarter of the calendar year,' he says. 'What happens to demand when you are at 18 weeks and others are not?'

'One of the surprises is that for some patients 18 weeks is too fast,' says Sasha Karakusevic, director of performance and development at South Devon Healthcare foundation trust. This creates the challenge of 'finding ways they can get the treatment they want when they want it rather than being pushed through a sausage machine'.

While the system can be further smoothed and waiting times at the referral, outpatients and diagnostic end could be reduced beyond 18 weeks, it may be that there a significant number of patients do not want to move through the system any more quickly.

Early achiever sites

SHA PCT Acute trust
East MidlandsDerbyshire CountyChesterfield Royal Hospital foundation trust
Derby CityDerby Hospitals foundation trust (other trusts to be brought in as far as possible)
North WestBlackpoolBlackpool, Fylde and Wyre Hospitals trust
BoltonBolton Hospitals trust, Greater Manchester Surgical Centre (BMI)
ManchesterCentral Manchester/Manchester Children's University Hospitals trust
Western CheshireCountess of Chester Hospital foundation trust
Halton and St Helens KnowsleySt Helens and Knowsley Hospitals trust
South CoastEastern and Coastal KentEast Kent Hospitals trust
South WestTorbay care trustSouth Devon Healthcare foundation trust

Yeovil District Hospital foundation trust, Taunton and Somerset trust

West MidlandsWalsall TeachingWalsall Hospitals trust
HerefordshireHereford Hospitals trust
Yorkshire and the HumberDoncasterDoncaster and Bassetlaw Hospitals foundation trust
South CentralHampshireBasingstoke and North Hampshire foundation trust
LondonCity and Hackney teachingHomerton University Hospital foundation trust
South East CoastMedway

Medway trust