The headlines proclaim that ministers have ordered a ‘crackdown’ on long waiting times. The Secretary of State has hit the newsrooms to declare that he will not tolerate ‘forgotten patients,’ languishing on waiting lists with no sign of treatment in sight. Are we back in the mid-noughties? Whatever happened to outcomes not targets?
In truth, shorter waits are an outcome in themselves, if you believe that patient experience is an outcome (which the Government – correctly – has made clear it does). We are experiencing one of the immutable laws of health politics – that waiting times matter to the public and politicians ignore them at their peril.
Politicians on all sides have at times tried – and failed – to move away from the focus on waiting time targets. It was Andy Burnham, following his days out in the NHS – an exercise he and the Labour Health team are repeating – who argued: “There will be less need for performance-managed top-down targets… targets and priorities should be set locally wherever possible.” Yet, by the time he returned to Richmond House as Secretary of State, Burnham had become a vocal champion of the importance of maximum waits. On the face of it Andrew Lansley appears to have undergone a similar journey.
Of course Lansley can claim that his approach is different, focusing on patients who might be neglected under the terms of the old 18 weeks target, and he is right (to a point). However, this is semantics: back in opposition, I am sure he didn’t envision announcing a headline-grabbing initiative containing the term ‘18 weeks.’ Nonetheless, this week’s announcement does not mean a fundamental shift in the Government’s approach. Indeed it is an extension of the policy already tried for encouraging single sex accommodation – a key marker for dignity.
Indeed the use – and effectiveness – of this approach is in many ways more interesting than the politics of waiting. There is now evidence about the effectiveness – and limits – of the policy instrument that the Department of Health intends to use to achieve its waiting time objective: fines for hospitals who fail to provide single sex accommodation.
I have blogged before about the impact of this approach on single sex accommodation breaches (interestingly, at that time the Government managed to ‘bury’ it’s good news, in contrast with today – perhaps suggesting that the media operation is improving). But it is now worth revisiting progress on mixed sex accommodation to see what clues it might offer for long waits. Readers may recall that a combination of transparency (publication of data at provider level) and financial incentives has had a big impact, with the number of patients being treated in mixed sex wards falling significantly. Performance has slipped back a little, with 1,244 breaches during October, compared to 1,079 in September. This is concerning, particularly given the relatively rapid progress made over the past year. But why is it occurring?
As Rob Findlay and Anthony McKeever point out in their excellent article for the HSJ, six NHS trusts now have more than 1,000 people whose treatment has been delayed by a year or more(you can see this on a map, which Rob Findlay has helpfully created). These providers – who are failing in a basic duty – account for a significant proportion of NHS long waiters. There are notable similarities with long waits. Thirteen providers had a breach rate in October of 2.5 per 1,000 finished consultant episodes or more. They accounted for 970 of the total breaches – or 78% of the total. In case you are interested, the thirteen providers are:
· Dartford and Gravesham NHS Trust
· Imperial College Healthcare NHS Trust
· Epsom and St Helier University Hospitals NHS Trust
· Barking, Havering and Redbridge University Hospitals NHS Trust
· Luton and Dunstable Hospital NHS Foundation Trust
· Gloucestershire Hospitals NHS Foundation Trust
· Great Western Hospitals NHS Foundation Trust
· Surrey and Sussex Healthcare NHS Trust
· St George’s Healthcare NHS Trust
· Brighton and Sussex University Hospitals NHS Trust
· Mid Staffordshire NHS Foundation Trust
· East Sussex Hospitals NHS Trust
· Barts and The London NHS Trust (which recorded 288 breaches in October alone)
The undignified 13 providers are failing NHS patients. They are failing to get right something which is routine for most other hospitals (100 acute NHS providers reported no breaches in October, as – incidentally – did all 20 independent sector providers). As with long waits, the abject performance of a few providers is stark.
It is also instructive to compare the undignified 13 against the list of 20 trusts identified by the Department of Health as being at risk of clinical and financial unsustainability. Four of the 20 – Barking, Havering and Redbridge University Hospitals NHS Trust; Surrey and Sussex Healthcare NHS Trust; Epsom and St Helier University Hospitals NHS Trust and Dartford and Gravesham NHS Trust – are on both lists. Barking, Havering and Redbridge also features amongst the six hospitals with most long waiters. There is a pattern here.
The challenge is that these providers (and many others on the list) are not having the levers put in place by the centre applied to them. Already running at a deficit, there is little point in commissioners fining them, as they know the money will just be recycled out of their budgets anyway. These providers are effectively operating to a different set of rules, leaving them unsusceptible to the sanctions which can be applied to better performing providers. Until this is changed, it is difficult to see how financial incentives – which have proved effective with the majority – will change improve the performance of the few.