On 11 March, NHS England’s Medical Director, Steve Powis, published his clinical review of NHS access standards. The proposals to change the four-hour A&E waiting target grabbed the headlines, but the potential changes to the 18-week waiting standard could have a profound effect on potentially millions of patients argues IHPN’s data analyst Graham Kendall.
The case for change
Digital appointments. The report argues that the NHS Long Term Plan’s proposal to introduce digital appointments will mean that “over the next five years patients will be able to avoid up to a third of face-to-face hospital-based outpatient visits, removing the need for up to 30 million outpatient visits a year.” One might be forgiven for thinking that this will make it easier to meet waiting time targets, but the report argues it will become harder because outpatients are where most RTT clock stops occur.
Perverse incentives and long waiters. While NHS England has long used targets to encourage specific behaviours, it has always been aware that targets can also create perverse incentives. For example, once someone slips over 18 weeks, the implementation of the waiting time standard means that treating them at 19 weeks or 49 weeks has no further impact on the provider’s performance.
Alternative providers at 26 weeks. So the combined effect of increased digitisation, possible perverse incentives and the imminent right to choice of an alternative provider at 26 weeks being rolled out from 1 April 2019 has led to NHS England is considering a new approach to measure waiting times.
The rise of the average
The proposal is to test the current 92% at 18 weeks measure against an average-based approach. What’s not stated is exactly what the average standard would be.
The graph above shows just how critical this might be for patients. Each dot represents a provider treating NHS patients, with the y-axis showing the number of people currently waiting at that organisation, and the x-axis showing the average time patients yet to be treated have so far spent waiting (the incomplete waiting time) . It’s important to remember they’ll wait longer than this before their treatment begins: this is the time spent waiting so far. The orange dots show organisations that currently have 92% of their patients within the 18-week standard, while the blue dots show organisations that are in breach.
What becomes immediately obvious when looking at the graph, is that an almost vertical line that corresponds to a mean waiting time of just over eight weeks, can be drawn between the orange providers who meet the current standard, and the blue providers in breach. This figure is close to the current median waiting time of 8.1 weeks across all providers, but considerably shorter than the 10.1 weeks for those organisations in breach of the 92% 18-week target.
This means if NHS England chooses an average target set at or below this 8-week line, then it represents a continued focus on waiting times at current levels. If the average target nudges above this level, then it’s effectively a relaxation which in turn means more delays for patients.
A cynic would say it would also be a clever reframing: talking about an average nine or 10-week wait sounds much better than 18 weeks, and let’s face it, the words “92nd percentile” aren’t exactly the sort of language likely to be heard in the typical pub.
This will have a real impact on people’s lives. Currently there are just over 556,000 people waiting over 18 weeks. 90% of them (495,000) are waiting in organisations in breach of the 18-week limit.
The jury is still out on this proposal. It could be a genuine reorientation to tackle waiting times, and specifically to ensure those waiting the longest get the prompt attention they deserve. But a shift from to an average in the order of 11 weeks or more would be a profound relaxation. In that case, NHS England could have pulled off a card trick whereby 11 weeks is far longer than 18.