- New system being introduced this year, with reporting due to begin in December
- Trusts’ concerns include tight treatment time, perverse incentives, a misleading picture of performance, and complex reporting
- Charities say it will make no difference
A major change to the measurement of cancer performance will produce misleading results and perverse incentives for some providers, several trust leaders have told HSJ.
The new process is being introduced by NHS England with the aim of better holding providers to account for waiting times where a cancer and diagnosis pathway is split across two organisations, as is common.
If the trust that diagnoses a patient will not be treating him or her, it must now refer them to the second provider within 38 days. The “treating provider” then has 24 days to start treatment, so the 62 day referral to treatment target can be met overall (see box below for full explanation).
Until now, 62 day performance has automatically split any breach of the deadline between the diagnosing and treating provider, regardless of when the patient was transferred between the two. This caused complaints about trusts which received patients late in the 62 day cycle being unfairly down rated.
Trusts are moving to collect and report on the new system through this year, and NHS England has said performance against it will begin to be published by December 2018.
A number of concerns about it have been raised with HSJ by senior figures at provider trusts.
- That 24 days may be unachievable for the treating provider. The current cancer treatment target is 31 days.
- That the system may mask very poor performers at either end of the pathway because breaches will be split equally between the two.
- There may be a perverse incentive for treating trusts to send patients back to diagnosing providers, so that their part of the waiting target is broken, and therefore the target breach is split.
- That in cases of more than two providers in a pathway, only the performance of the two providers that have had the longest periods of contact with the patient will be measured, masking good or bad performance by other providers involved in the care.
- Reporting is more complex and time consuming.
The Christie Foundation Trust chief operating officer Fiona Noden said the new system potentially left treating trusts within an unreasonably short time. “For very complex treatments 24 days is a very short period of time to work the patient up,” she told HSJ.
One director at an NHS provider said the new system had created various “anomalies”, and that there was a “lack of understanding” about how this would affect many pathways which involved three or more providers.
The source also raised concern about the approach giving a misleading impression of performance – for example if a diagnosing trust far exceeds the 38 days, but gets to split responsibility for the overall breach with a treating trust which has only just missed its 24 days.
“That is wrong, it should be allocated to the provider that let that patient down,” the director said. “A provider with a very poor performance record will start to look better even if they have done nothing different.”
One acute trust chief executive said the new approach was too simplistic, stating it could make poorly performing trusts look better, and well performing trusts look worse, without either having changed.
Another chief told HSJ there was now a perverse incentive for treating trusts to send patients back to diagnosing trusts, so they missed their part of the target and would share any breach.
“There is much more ‘to and fro’ between the providers,” the source said. “Tertiary cancer centres will send patients back claiming that they have not been fully worked up, thereby splitting the breach with our [diagnosing] trust [because it pushes us over the 38 day target].”
An NHS England spokeswoman said: “The NHS is making this change to create more transparency in patient pathways from referral to treatment for cancer patients. Overall performance reporting will not change at population level or overall for England, however by making the process more transparent, it will be easier to identify where delays in the treatment pathway happen and target improvement in the short and long term.”
Cancer charities said it would not improve care overall. Andrew Kaye, Macmillan Cancer Support head of policy, said: “Simply changing timeframes and highlighting areas of concern will not address the root cause [of delays].” Sara Bainbridge, Cancer Research UK policy manager, said the new measurements were “not likely to have any impact on patients”.
Guidance in April from NHS Digital on the new approach said the change should “improve” patient care and is “intended to ensure consistency across the country and promote collaboration between providers”.
This story was updated on 15.45 on 25.9.18 to reflect new information provided by NHS England.
How will the new system work?
The new system will allocate breaches to the provider that has caused the delay.
The two providers responsible for diagnostics and treatment will share the breach if both failed to meet the 38 day and then the 24 day limits. For measurement purposes, each trust will be allocated half a breach for each patient not treated on time.
A treating provider will take all the credit if it meets the 62 day target despite the patient being referred late. Similarly, a diagnosing provider takes all the credit if it refers a patient for treatment within 38 days but the receiving trust fails to meet its own portion of the 62 day target.
However, if there are three are more providers, the breaches or successes of the system will only be allocated to the two providers in the process who had the longest periods of contact with the patient. Similarly, a trust that has breached the entire 62 day wait by itself will not be allocated all the failure, if the treating trust fails to meet the 24 day limit.
NHS Digital Guidance, April 2018. Comment to HSJ, August 2018