Management of NHS waiting lists

NHS patients have the right to receive elective pre-planned consultant-led care within 18 weeks of being referred for treatment. In 2012–13, there were 19.1 million referrals to hospitals in England, with hospital-related costs of around £16 billion. The waiting time performance standards are set by the Department, which has overall accountability for service provision and value for money, while trusts’ performance against the standards is collated and published by NHS England. The standards introduced in 2008 are that 90% of patients admitted to hospital, and 95% of other patients, should have started treatment within 18 weeks of being referred. Since April 2012 there has also been a standard that addresses the perverse incentive for trusts to focus unduly on patients recently added to waiting lists. In April 2013, NHS England introduced zero tolerance of any patient waiting more than 52 weeks. The latest figures at the time of our hearing showed that all these targets are being met.

The Department cannot be sure that the waiting time data NHS England publishes is accurate. NHS England publishes waiting time data, based on information provided by trusts, but it has not made sure that this is consistent, complete and accurate. Trusts are struggling with a hotchpotch of IT and paper based systems that are not easily pulled together, which makes it difficult for them to track and collate the patient information needed to manage and record patients’ waiting time. The National Audit Office (NAO) found that waiting times for nearly a third of cases it reviewed at seven trusts were not supported by documented evidence, and that a further 26% were wrong. Multiple organisations, including trusts themselves, clinical commissioning groups, Monitor, the NHS Trust Development Authority and NHS England have a quality assurance role. There are also plans for an internal audit of trusts’ data and various forms of external audit and spot checks. However, we are not convinced that responsibilities have been clearly defined. Recommendation: The Department must work with NHS England, Monitor and the NHS Trust Development Authority to agree clear actions, responsibilities and a timetable for obtaining assurance that trusts’ systems and processes for monitoring waiting lists are producing consistent and reliable data. The data should be audited by someone independent of the trust it relates to.

The guidance is complex and allows variations between trusts in the way they manage and record waiting times. The NHS England guidance on waiting times allows trusts some flexibility in how they manage patients’ waiting time so that they can reflect local circumstances. But there are unintended consequences, such as variations between trusts in the number of cancellations by patients they allow before patients are referred back to their GP and placed at the back of the queue. These differences reduce the comparability of trusts’ waiting times and mean GPs and patients cannot be sure they are choosing the hospital with the shortest wait for treatment. The guidance itself is long and complicated, which contributes further to errors in recording waiting times. 5 Recommendation: NHS England must work with trusts to identify weaknesses in current guidance and inconsistencies in the way it is applied, and simplify it by the end of 2014.

The current regime of financial penalties for trusts that do not achieve the waiting time standards is not being used to drive improved performance. At the time of our hearing commissioners were required to impose fines on trusts for not meeting waiting time standards, but in 2012–13 80 trusts that had failed to meet at least one of the standards were not fined. It may be that in some circumstances financial penalties can make the situation worse, and from 2014 NHS England’s standard contract will allow clinical commissioning groups some flexibility in how they apply sanctions. However, 46 of the 80 trusts which had failed to meet the standards also had no conditions, such as recovery or improvement plans, attached to not being fined. Recommendation: Whether or not clinical commissioning groups apply fines, they should agree clear performance improvement plans with those trusts which fail to meet waiting time standards.

Too much stands in the way of patients making informed choices about their treatment. Patients do not fully understand their rights and responsibilities under the NHS Constitution—including their right to be treated within 18 weeks and how the time they wait can be affected if they cancel or do not attend appointments. Individual hospital policies on access to treatment are often out of date and not publically available, and how trusts communicate with patients varies, with some, for example, sending text confirmations ahead of appointments and others not. It should be a lot easier than it is for patients to interact with hospitals and understand when they will see a consultant. Patients are also more likely to turn up for appointments when they have been able to choose the date themselves, which would help the NHS reduce the annual cost of up to £225 million due to patients not attending first outpatient appointments. Recommendation: NHS England must work with clinical commissioning groups and trusts to make sure that patients are clear about their rights and responsibilities under the NHS Constitution.

NHS England faces a challenge to gain acceptance for the new e-Referrals system, given the difficulties with Choose and Book. The Choose and Book appointment booking system—an online electronic booking service for patients and healthcare professionals—has been a missed opportunity to improve patient care and data quality. It cost £356 million to March 2012, but has had a chequered history and is underutilised, which means that annual savings of up to £51 million are being missed. Not all hospital appointment slots are available to be booked on the system and only half of all possible GP-to-first outpatient referrals are booked using it. Choose and Book is to be replaced by e-Referrals with the Department aiming for it to be used for all referrals within the next five years, sooner if possible. The use of e- Referrals should reduce the number of data errors and allow patients to track and 6 manage their hospital appointments. However, given the difficulty NHS England has had in getting GPs and others to use Choose and Book, we are sceptical about its ability to achieve full utilisation of e-Referrals. Recommendation: To realise the full benefits of e-Referrals, NHS England must develop clear plans for how it intends to build up confidence in and utilisation of the new system.

The setting of clear standards for waiting times has driven improvements. The success in reducing waiting times led to discussion at our hearing about whether there is a consistent understanding of the key indicators of effective leadership in hospitals, which might in turn lend themselves to a more comprehensive set of NHS standards. These standards could include other areas of NHS performance such as increased weekend working and the use of agency staff, and the impact these have on clinical outcomes. The Department wanted to reflect further, and we accept that in a system as complex as the NHS the answer is not straightforward; for example, different parts of the business are interrelated and focusing on one aspect of performance can have unintended consequences in other areas. We look forward to seeing the Department’s views in its response to this report. 7 1 Improving the quality of elective care waiting time data

We asked about the audit arrangements for waiting time information, given that more than half of trusts did not have either internal or external audits of their data. The NHS Trust Development Authority agreed that there is a need to tighten up and enhance both internal and external audit. Monitor emphasised that there is a need to be clear about what should be expected from internal audit of the data. It said that there is a case for looking at reinstating the kind of external audit the Audit Commission used to do, and it added that having an independent overview is helpful. In addition, the Department said it intends to look at the role that the Health and Social Care Information Centre could play as a centre 7 Qq 1, 35; C&AG’s Report, paragraph 2.16 8 Q 35; C&AG’s Report, paragraph 2.1 9 Qq 1–4, 15–16, 23, 35; C&AG’s Report, paragraph 2.32 10 Q 49 11 Qq 35–37; C&AG’s Report, paragraph 6 12 C&AG’s Report, paragraphs 2.25–2.27 9 of expertise, validator and spot-checker on the accuracy of trust data. However, the evidence we received did not provide a clear system-wide view of who will be responsible for what.13

NHS England is responsible for the written guidance given to trusts, which sets out how they should measure and report waiting times. The guidance is lengthy and underpins the ‘rules suite’, which alone runs to 36 pages.14 Both Northampton General Hospital and Homerton University Hospital told us that it was a significant challenge to ensure that their staff were trained in how to interpret the guidance in all circumstances. Northampton General Hospital did tell us that the guidance had improved since it was first issued.15 However, the Department accepted that the guidance needs to be simplified further.16

Both Northampton General Hospital and Homerton University Hospital told us that there was some local interpretation of the guidance, which made it more complex to ensure that all of their staff were measuring waiting times consistently. The guidance does allow trusts some discretion in how it is applied, and Northampton General Hospital explained that this was intended to take account of differences in how hospitals are run.17 However, differences in interpretation by trusts can result in patients being dealt with differently. For example, the guidance allows for variation in how trusts handle patients who fail to attend appointments; some trusts allow patients only one cancellation before referring them back to their GP, while others allow three cancellations.18

Different interpretations of the guidance can reduce the comparability of information about trusts’ waiting times. As a result, GPs and patients cannot reliably identify the hospital with the shortest wait for treatment, which undermines their ability to be informed users of the system. For example, those trusts allowing more cancellations by patients are at greater risk of breaching waiting time standards.19 The guidance also allows for different approaches to the length of time the waiting time clock can be paused, which can affect recorded waiting times. For example, some trusts end pauses on the date when patients have said that they are available for treatment, whereas other trusts pause the clock until the day of, or the day before, patients are admitted.20

Both Northampton General Hospital and Homerton University Hospital told us that waiting lists have come down as a result of the introduction of waiting time targets.21 We asked the Department whether it was considering introducing similar targets to promote best practice in other areas associated with poorer outcomes for patients, such as weekend care and the excessive use of agency staff. There are currently no national standards for 13 Qq 35–37, 40 14 Qq 25–28; C&AG’s Report, paragraphs 2.4–2.5 15 Qq 1, 11, 13, 30 16 Q 49 17 Qq 1, 11, 13, 30; C&AG’s Report, paragraph 2.5 18 Qq 80, 88; C&AG’s Report, paragraphs 2.5, 2.7 19 Qq 80–81; C&AG’s Report, paragraphs 2.5, 2.7 20 C&AG’s Report, paragraphs 2.5, 2.9–2.10 21 Qq 31, 33 10 either of these areas.22 In our view the quality of leadership in hospitals is absolutely essential in driving improvement, so we also asked the Department whether it was looking at a package of measures to assess leadership.23

The Department told us that it would need to reflect further on the merits of wider targets—in particular relating to weekend care and agency staff—so that it understood the advantages and disadvantages of such an approach. The Department also noted the importance of understanding any unintended consequences of introducing targets in one area, stressing that hospitals are complex and interconnected organisations.24

The Department agreed with us about the importance of effective leadership and the need for a set of transparent measures that are indicators of good leadership. It told us that, under the new inspection regime, the three Chief Inspectors were working on identifying the essential features of a ‘good-performing’ organisation. The Department also confirmed that building a package of measures to inform a view of leadership was very much behind its aims for the new inspection regime.25 22 Qq 89, 92 23 Qq 94–95 24 Qq 89–91 25 Qq 94–96 11 2 Improving waiting time performance

We were interested in the financial incentives for trusts to achieve the waiting time standards, and asked about the use made of fines when trusts breach the standards. At the time of our hearing there was a system of mandatory fines, yet the NAO found that 80 trusts breached the waiting time standards in 2012–13 and were not fined. Forty-six of the 80 had no conditions, such as recovery or improvement plans, attached to not being fined.26

NHS England’s view was that in some circumstances fines will not improve the situation, and could make it worse, and that there should be local flexibility to decide whether to fine.27 There can be factors behind a trust’s failure to meet the standards which are beyond its direct control. For example, Northampton General Hospital said that emergency care was the biggest pressure it faced, and Monitor told us that if there is a sudden surge in demand for emergency care, “the only way” to deal with it is to postpone some of the elective care.28 However, if clinical commissioning groups do not make sure that trusts have, for example, improvement plans in place, they cannot be confident that the underlying reasons for breaching the standards are being tackled. Monitor told us that it, and the NHS Trust Development Authority, would step in where a trust is continually missing the standards.29

NHS England’s 2014–15 standard contract will allow clinical commissioning groups some flexibility in how they apply sanctions, so that these operate in the best interests of patients. In addition, clinical commissioning groups will be allocated a quality premium of up to £5 per head of population, based on their performance in meeting the requirements of their local population, including elective care waiting times.30

Effective communications with patients, and helping them to understand their rights and responsibilities, is an important part of managing waiting times effectively. It is good practice for trusts to have a publicly available access policy clearly setting out how the waiting time rules will be applied locally. However, only 25% of 158 acute trusts had published their access policies online, and of the 118 access policies reviewed by the NAO only 17 referred to all three 18-week waiting time standards and were up-to-date.31 Both Homerton University Hospital and Northampton General Hospital agreed that work was needed to make their access policies more patient-friendly.32 The way trusts communicate with patients also varies in other ways. The NAO found that 74 out of 158 trusts send patients a letter with an appointment date and time; 42 contact patients by phone; and 33 send an invitation-to-book letter requiring patients to phone and make an appointment. Only 55 trusts send text message appointment confirmations; Homerton University 26 Qq 76–79; C&AG’s Report, paragraphs 3.10, 3.12 27 Q 77 28 Qq 32, 74 29 Q 79 30 Qq 76–79; C&AG’s Report, paragraph 3.13 31 Q 14; C&AG’s Report, paragraph 2.6 32 Qq 12–13 12 Hospital told us that when it first started doing this the number of patients failing to attend appointments fell, although that had now levelled-off.33

The Department acknowledged that there is more to be done to increase patients’ understanding of their rights and responsibilities. There is a need for patients who are paying for the system to understand that they are entitled to receive treatment within a certain period of time, and to be an informed user of the system. Not enough know that they can choose where to be treated, or understand the consequences if they do not turn up for appointments. The Department told us that it must make it easier for patients to interact with trusts to organise their appointments, as patients are more likely to turn up for appointments that they have chosen.34 The NAO estimated that the 1.6 million patients that failed to turn up for first outpatient appointments in 2012–13 cost the NHS up to £225 million.35

The Choose and Book system is an online booking service for patients and healthcare professionals. Choose and Book was introduced in 2004 and had cost £356 million to March 2012.36 The use of Choose and Book by GPs is variable: Northampton General Hospital told us that most, but not all, of its appointments were made using Choose and Book, whereas Homerton University Hospital said that a significant number of referrals to it were made on paper.37 NHS England said that many GPs like Choose and Book, and that half of all referrals are received this way. However, not all appointment slots are available through Choose and Book, which limits its usefulness. The NAO estimated that additional savings of up to £51 million every year could be made if Choose and Book was used to book all appointments.38

NHS England told us that it is replacing Choose and Book with the NHS e-Referral system in 2014 and extending it to a wider range of healthcare professionals including, for example, physiotherapists and opticians. It will have some improved features such as mobile apps, so that patients can more easily change appointments and track where they are in the system. The Department said that the aim is that all referrals are made through the new system within the next five years, sooner if possible. It also expects that this will reduce waiting time data errors.39

Given the underutilisation of Choose and Book, we asked what was being done to make sure that e-Referrals does not suffer the same problems. The NAO’s January 2005 report Patient Choice at the Point of GP Referral said: “The Department needs urgently to address the low level of GP support for their plans for implementing choice at referral”.40 NHS England told us that in developing the e-Referral system it has engaged with GPs by 33 Q 18; C&AG’s Report, paragraph 3.30 34 Qq 49, 80, 81 35 C&AG’s Report, paragraph 3.31 36 C&AG’s Report, paragraph 3.26 37 Qq 5–8 38 Qq 50, 54; C&AG’s Report, paragraphs 3.26–3.27 39 Q 49 40 Q 53; C&AG’s Report, Patient Choice at the Point of GP Referral, HC 180 Session 2004–05, 19 January 2005, paragraph 15 13 running trials. It also said that it is looking at what incentive or penalty system is most appropriate to encourage the use of e-Referrals. NHS England told us that it had tried to use financial incentives to encourage GPs to use Choose and Book, but that this had not been effective. It said that it would like to make the e-Referral system mandatory.41 41 Qq 55, 59, 61 14