Patients and the NHS staff are often unaware of the legal right to be treated within 18 weeks. Yet with the numbers waiting for consultant led treatment increasing, what is keeping the NHS from achieving its targets?

Waiting room

Waiting room

Sometime in the next couple of months, the NHS is likely to reach a milestone of 3 million people waiting for consultant led treatment. And it is likely that an increasing percentage of them will have been on hold for more than 18 weeks.

Since 2008, NHS England has had a target of treating 90 per cent of elective inpatients and 95 per cent of outpatients within 18 weeks. Patients have a legal right to be treated within this time, although both they and the NHS staff treating them often seem unaware of this.

‘One of the biggest problems is having good data to understand where people are coming from - how they have been put on the list’

As we move towards the 2015 general election, that target will become intensely political, with growing pressure on the NHS to improve performance. Trusts have already been told they must clear their backlog of long waiting patients over the summer.

But what is holding the NHS back from achieving its targets? The answer is complex. From 2011 until earlier this year, it was meeting targets. Then it started to miss the 90 per cent marker.

Waiting lists generally rise in the summer and fall in the winter, but this year that dip does not seem to have happened. Instead the median wait has increased.

Adjustment period

Holly Dorning, research analyst at the Nuffield Trust, feels this may be due to trusts already making efforts to ensure their backlog of long waiting patients is cleared - which may impact on their ability to treat new patients. “I do get the sense that this is a bit of an adjustment period,” she says.

“We are not going to see anything rosy in the next few months.”

‘There can be a gap in understanding at directorate level’

Long term changes could also affect the length of the list, as an ageing population is likely to need more interventions.

Mark Newbold, a trustee of the NHS Confederation and chief executive of Heart of England Foundation Trust, agrees that many trusts are treating long-waiting patients - often in order of when they were referred - which may be causing a temporary dip in the 18 week achievement.

But will trusts be able to respond to the strong message from NHS England to sort out waiting lists before we enter the next period of winter pressures?

In June, the government announced £250m would be made available to help providers clear waiting list backlogs. How much each area will receive is not yet clear, but the move will focus attention on the 18 week target and the renewed pressure for trusts to meet it.

The Nuffield Trust says in general, the number of people treated as in- or outpatients has remained relatively static; capacity cannot be turned on at the touch of a button. And some specialties, such as orthopaedics, have long standing problems.

Karen Hyde: Accurate reporting is achievable

Eighteen week referral to treatment is not a new concept, and regardless of common myths, it is here to stay.

Experience shows that some staff have placed 18 weeks into the “too hard to do” tray; they are so busy delivering the many conflicting challenges of running a hospital that finding time to read and understand the rules and train staff on their application is clearly unattainable for some.

When discussing 18 weeks, we know instantly if the person we are listening to understands the rules simply from the language they use. The target has precise terminology: clock starts, clock pauses, active monitoring, clock continues, planned patients, not applicable to 18 weeks, and so on. When you are fluent in 18 week terminology, you have a fighting chance of achieving the standards.

The 18 week RTT rules are very clear in direction with regards to when a clock starts and when a clock stops. Between the start and stop, a number of events will occur. It is absolutely key to document these events accurately and use the correct RTT status codes to do so.

There is a tendency for staff to be resistant to “targets”. But following a recent report from the National Audit Office and the fact the waiting list has nearly reached 3 million, there is a requirement to embrace this subject more than ever.

The misconception is that the RTT standards are about how to fit a patient pathway into the rules. This is not the case; the reality is that accurate and timely recording of clinical decisions will enable staff to understand what the patient is waiting for and, moreover, how to provide what they are waiting for within their entitlement.

Service managers worry that 18 weeks is impossible within the constraints of their specialties; and there is a propensity to make this far more difficult than it needs to be.

18WeekeLearning delivers the key to consistent, accurate recording of patient pathways to provide patients, trusts and NHS England with the desired outcomes.

A comment that we hear far too often is that if patients were aware of their rights, they would be beating down the doors of their local hospital. Imagine the ensuing carnage!

We know that accurate reporting of 18 weeks is achievable because we have delivered it in a number of different settings.

Karen Hyde is director of 18WeekeLearning

Listless trusts

But to even begin to meet this challenge, trusts need to understand what their waiting list looks like. There are currently six trusts not reporting figures in England, which may mean the 3 million mark was passed some months ago if their data was included. For some, the reasons they cannot report seem to be about the availability of good quality information showing who has been waiting and for how long.

A National Audit Office report earlier this year suggested hospitals were struggling to correctly record how long people waited, and that incomplete or inaccurate records were commonplace.

‘This is not about doctors’ clinical decisions being challenged – it is about understanding how the administration of clinical decisions should work’

Of 650 orthopaedic patient records it looked at across seven trusts, only 43 per cent were complete and accurate. It found some patients’ waits had been underestimated - but also that some were recorded as being longer than 18 weeks, when the patients had actually been treated within the time limit.

What does this mean for trusts? Inaccurate or missing data suggests they do not know the scale of the challenge they are facing - in some cases they may be underestimating it, while they will overestimate in others.

“One of the biggest problems is having good data to understand where people are coming from - how they have been put on the list,” says Ms Dorning.

A major challenge for trusts is the notoriously complex 18 week reporting rules, which a wide range of staff will be involved in applying across their organisation.

Understanding the rules

While much of the data to show whether the target is being achieved will be entered by administrative staff, a much broader range of staff will need to be aware of the rules to ensure patients are offered the chance to be seen within 18 weeks. This will include many clinicians and managers.

“We have found, as a trust, that when we go into an individual specialty that is struggling [with the targets], there can be a need for some training.

“There can be a gap in understanding at directorate level,” says Dr Newbold.

Ensuring all members of staff have the knowledge they need to play their part is difficult, says Karen Hyde, who has pioneered online training for staff on 18 week targets with Nicola Cooper at 18WeekeLearning.

‘There are financial penalties for trusts if patients wait too long, but they may also lose patients who choose to go elsewhere’

To achieve this will require differentiated training. They have developed a module for staff who need only have a basic knowledge of the system, and more advanced ones for closely involved staff. Clinicians - whose choices and data capture on clinic outcome forms are vital - get their own module.

“This is not about doctors’ clinical decisions being changed or challenged,” Ms Hyde says. “It is about helping them to understand how the administration of clinical decisions should work.

“Anyone who updates the trust’s patient administration system, or makes a decision about a patient who has been referred or who is waiting for treatment, or who has responsibility for staff who do this, needs to know about 18 weeks.”

Ms Hyde has been involved in data validation exercises that pull apart waiting lists to ensure details have been entered correctly - that the clock starts, pauses and stops are accurately recorded, for instance. Often, these can uncover severe problems, but the news is not always bad.

“We have worked with trusts that are in a better position than they anticipated,” she says.

Avoiding penalties

Ms Cooper urges trusts to “get it right first time” by ensuring staff know what they are doing and what is required.

“There are financial penalties for trusts if patients wait too long, but they may also lose patients who choose to go elsewhere,” she says.

“If they have to do a large scale validation exercise, there are extra staff costs.”

‘There is likely to be ever more pressure on trusts to manage their waiting lists well and achieve the standard’

A useful first step is a baseline assessment of what staff know. While the results of this can be shocking, it helps to identify gaps in knowledge and concentrate minds on what needs to be done.

Ms Hyde says staff can then work through training materials online at a time that suits their commitments, before being reassessed.

The e-learning package allows managers to get detailed feedback on who has logged on and what they have done. And it is updated regularly to reflect changes to the regulations.

With referrals rising in many areas, there is likely to be ever more pressure on trusts to manage their waiting lists well and achieve the standard. Investment in training staff can avoid problems later on.

Case study: Sheffield Teaching Hospitals FT streamlines training to reflect staff needs

Sheffield Teaching Hospitals Foundation Trust is a high performing, respected organisation. However, like many other trusts that have a reputation for delivering good clinical outcomes, more and more patients have chosen the trust for their care in the past 12 months. This has resulted in a sustained, significant increase in demand, which has begun to make achieving the 18 weeks standard more challenging.

As a consequence, the trust quickly developed an action plan to put in place new processes, additional capacity and training to ensure it could continue to meet the standards.

Staff in some directorates have already received comprehensive training, but it was felt that expanding access to the training would engage more staff in delivering a timely response at each stage of the 18 week process.

The trust introduced a new, easy to follow e-learning package designed to be simple to understand. In addition, it has some fairly powerful management monitoring information showing who has logged in, what they have done, and so on.

The package was also regularly updated to reflect rule changes.

Over 1,300 employees were offered the training. These were largely admin and clerical staff, but also included managers and a number of clinicians and nursing staff. There was no “three line whip” - care groups could decide who would benefit from the additional training.

The first step was to establish the level of understanding this cohort of staff had of the workings of the 18 week standard. All were invited to attend a short assessment session, which helped determine whether particular groups of staff or areas needed support.

Training sessions were also held with managers on the ground with the intention that each specialty would be able to develop additional training for their own areas, addressing specific issues.

At the end of March - just six weeks after the project begun - the 1,300 staff were asked to take a second assessment and it was clear that the level of training and understanding had increased significantly.

Directorates are now developing specialty based modules to support the system and run training. Some directorates are setting up workshops for staff, while a project group has been established to look at difficult coding issues and make decisions on them. Some areas are also considering making the 18WeekeLearning course mandatory for certain groups of staff.

Overall, the experience has been very positive and the trust is beginning to see an impact.