IHPN’s data guru, Graham Kendall, looks at the NHS’ progress in meeting it’s recent commitment to stabilising waiting lists and what lessons need to be learned to cut waiting times.
The latest waiting time figures show that last year’s main elective care target – to stabilise waiting numbers to March 2018 levels – was missed by a country mile. By last summer, IHPN was already publicly predicting we were badly off track and it is now increasingly clear that last year’s approach marked a strategic break from previous years. That new approach did not work, and in turn it could herald more problems into the future.
The main waiting time target last year, laid out in the 2018-19 planning guidance, was that the number of patients on the incomplete pathway ‘will be no higher in March 2019 than in March 2018’ and ideally reduced. The revised version of that figure published in May 2019 was 3,852,414. By contrast, the official number of patients waiting to start treatment at the end of March 2019 was 4,232,436, so nearly 10% above where it should have been.
To be fair, there were a quarter of a million people estimated to be waiting in March 2018 at Trusts that did not report their waiting figures. By 2019, this number had gone down to 112,000, so the change in the total number of people waiting when counting everyone, will have gone from 4,102,999 to 4,344,489.. This equates to missing the target by 6%, or an additional 241,490 waiting. Either way, it’s a bad miss and with numbers like this it’s worth remembering that this is not just a figure. It is close to a quarter of a million people – real people, suffering genuine pain, discomfort and stress.
Bucking history is difficult
The target was always going to be challenging to achieve. It has been close to a decade since we’ve seen annual reductions in the total number of people waiting, and that was achieved following years of sustained effort, and crucially new elective capacity, achieved primarily by growth in numbers of people treated by independent providers.
By contrast, the last few years have been marked by flat acute elective volumes for both NHS and independent providers treating NHS patients. If we look at the historic trends for the number of people waiting compared to the previous March, there is a distinct pattern.
Up to last year, during every year since 2010, the number of people waiting has risen steadily into the summer and then reduced during the autumn, to be followed by a rise at the beginning of the year. The scale of this trend has varied from year to year, but not the overall shape.
It is notable that only in 2011-12 was the number of people waiting at the end of year below its previous March levels. It is no coincidence that significant new provision from independent providers came on stream that year.
Up to around September, the number of people waiting in 2018 was consistently just above the mean performance for previous years. Numbers then failed to dip significantly in the winter, only to rise again in March. The overall pattern is still clear: the service failed to buck the historic trend.
Strategic options: increase capacity or constrain demand
By looking at the rolling 12-month average of new starts, i.e. patients joining the waiting lists, we can largely smooth out the effects of seasonal variation.
We see a steady upward gradient in the number of new starts from September 2016 (earliest date available for a 12-month rolling average). This flatlines around August 2017, begins to creep up slowly until September 2018, and then resumes its earlier trajectory for the rest of 2018-19.
This flatlining can only really be explained by a concerted effort to constrain demand, i.e. to restrict the number of people beginning RTT pathways. This is a quite different approach to that which succeeded in the earlier part of the decade.
A natural experiment
Inadvertently, the different approaches taken to tackling waiting lists at the beginning and end of the decade have created a natural experiment whereby we tried first to reduce waiting numbers by increasing capacity, and then, a few years later, attempted the same goal but by constraining demand.
Increasing capacity worked, but constraining demand turned out to be unsustainable and ultimately ineffective. This is not that surprising if we consider the underlying factors: regardless of changes to approaches and referrals, people still develop conditions at the same rate, so constraining demand only backs up the problem.
The only way in which constraining demand could become a sustainable solution is if it were to be supported by a considered policy effort to encourage people to seek treatment elsewhere at scale, i.e. choose privately funded provision. However, that did not materialise, nor did the other alternative, to increase capacity, and so we have missed the target.
Prospects for the future
2019-20 planning guidance published last December suggests that providers will be able to “further improve their waiting list position during 2019-20… so that the waiting list number will decrease [beyond the March 2018 level]”. The guidance does talk about increasing elective treatment, so there is some at least implicit recognition of the need for greater capacity. However, given this target has been clearly missed and the commitment to meet 18 week target has been quietly dropped from NHS Mandate, the future for many could be yet more waiting.