The NHS has supposedly been given £1 billion to tackle referral-to-treatment (RTT) waiting times, although after NHS England’s higher priorities have been dealt with (dealing with deficits, emergencies, cancer, mental health, and primary care) there may not be much left over.
Nevertheless NHS England’s principles are surely the right ones: put clinical priority patients first, and then do what we can for the routines.
But those principles are under threat. And to see why, we need to examine how the RTT money could be spent.
Safety first
The principled approach to RTT waiting times would maximise patient safety.
Most importantly, that means short waiting times for first outpatient appointments. Remember that only a minority of cancers are referred on a two week pathway – we need to see all new outpatients quickly to find out what’s wrong with them.
Next, making sure that patients who attend regularly do not have their appointments put off. People are going blind because their macular degeneration or glaucoma checks are being delayed to make way for RTT patients – even though they are clinical priorities and should therefore take precedence over routine conditions.
Finally, treating the very longest-waiting patients. It makes little difference, from a clinical safety point of view, whether the typical waiting time is 18 or 22 weeks RTT. It is the extremes that matter, so both existing and extra resources need to be focused on those patients who are waiting the very longest.
Happy doctors, unhappy spin doctors
That all sounds great, but we need to recognise that a safety-led approach will not have much impact on the waiting times statistics.
Many patients are discharged following their first outpatient appointment. So if first outpatient waiting times are kept short, lots of patients will be discharged after only a short wait. That reduces the number of short-waiting patients on the waiting list without much affecting the number of long-waiters, so the headline performance – usually (though unwisely) measured as the percentage within 18 weeks – will be worse.
Regular attenders are not covered by the RTT targets at all, so devoting capacity to them leaves less capacity to improve RTT performance.
What about the very longest waiters? Clearly, treating them does improve RTT performance because it reduces the number of over-18-week waiters without affecting the number of short waiters. However these patients have ultra-long waits for a reason – it is difficult to find the capacity to treat them, and they tend to be expensive. So focusing on them means treating fewer patients.
Managing to the target
If on the other hand your concern was simply to make the numbers look good, you could take a completely different approach: minimise the number of over-18 week waiters, and maximise the number of under-18 week waiters. That achieves the highest possible percentage within 18 weeks when all specialties are added together, and is an approach that many local services already use.
It is a simple approach. Want to minimise the over-18 week waiters? Then treat the cheapest and easiest ones, in outpatient-dominated medical specialties, and daycase-dominated surgery such as ophthalmology.
Want to maximise the under-18 week waiters? Then let waiting lists grow so that all routine patients are forced to wait nearly 18 weeks (and consider imposing minimum waiting times). In particular, increase the waiting times for first outpatient appointments so that fewer patients are discharged after only a short wait.
Although this approach would produce attractive RTT statistics, it also means that timely access to NHS services would depend not on clinical need but on (the NHS’s) ability to pay.
So if you needed something expensive like a hip replacement then you’d be kept waiting with only vague promises of treatment. Unsuspected cancers would be detected too late because of long delays in outpatients. And patients would continue to go blind as their regular appointments were put back.
These are the very harms that waiting times standards were supposed to prevent.
What will the government do?
Whether it is pushed out centrally, or awarded bid by bid, the centre will have to decide which approach to follow when allocating the extra RTT money.
NHS England have already laid out their overall priorities, and they point clearly towards the patient safety approach. The only way that “managing to the target” could prevail is if the government (in the shape of the Secretary of State for Health) were to insist on it via next year’s Mandate.
The current Secretary of State, Jeremy Hunt, has been a staunch champion of safety and quality, and it would be peculiar if he were now to place himself in opposition to patient safety by insisting that the targets should be met regardless of the consequences. Nevertheless the early indications are that this is precisely the line he is taking.
It is in tough times like these that people’s values are really tested. As discussions over next year’s Mandate take shape, we will find out how sincere the government really is when it comes to patient safety.
