What is an unacceptable time to wait for non-urgent care?

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‘NHS 'waving white flag' as it axes 18-week waiting time operation target’

Ever since the alarming headline above was published by the Guardian on March 31st, Simon Stevens and 18 Week Referral to Treatment Targets has been, quite rightly, the subject of intense scrutiny and debate.

Firstly, legal advice was quickly commissioned by the Labour party to advise on the legality of this departure from the NHS constitution. It has now been suggested that by not obliging NHS England to compel hospitals to treat the required 92% of patients within 18 weeks of being referred by their GP, the Health Secretary has broken the law. This is understandably a claim that has been refuted by Mr Jeremy Hunt.

Clare Marx, president of the Royal College of Surgeons was also very vocal from the outset and suggested in an interview with the Guardian that by relaxing the 92% threshold, ‘’we risk returning to the days of unacceptably long waits for elective surgical treatment.”

The question then becomes, “what is an unacceptable time to wait for non-urgent care?” Some would argue that there may be no correct answer to this question outside of the 18 Week Targets embedded in the NHS constitution. Still, that did not deter ITV News Presenter Julie Etchingham from posing the question directly to Mr Simon Stevens. His reply should come as no surprise since both Jeremy Hunt and Simon Stevens have made it clear that as NHS constitutional rights go, none are absolute, least of all the right to be seen for non-urgent care within 18 Weeks. This has to be balanced against arguably more important rights. For the next year, replied Stevens, ‘the most important thing that the NHS has got to get right and improve on will be – A&E services, cancer and mental health and GP services’.

Only a few can convincingly argue that this balancing act with regards to NHS constitutional rights isn’t a financial necessity. If providers are to ensure world class cancer care, meet A&E targets and provide better access to GP services then something has to give. We must at least agree that with finite resources, we have to manage conflicting priorities if we are to move forward with a clear plan of how to ensure we do the absolute best for our patients.

Rob Findlay of Gooroo, a trusted voice on the subject, suggests that the way forward necessarily requires a focus on the needs of patients. ‘… let’s stop managing to the target, and start managing according to the needs of patients. In practical terms: stop focusing on lists of patients who are about to breach an arbitrary waiting time. Instead, let’s return to the time-honoured principles of treating urgent patients quickly and routines broadly in date order. Then patients will always be scheduled safely and fairly, and waiting times for routine patients will depend in a predictable way on the size of the waiting list’. Findlay makes a good point about the need to schedule patients ‘safely and fairly’. I would add that clinician engagement is an integral part of ensuring patients come to no harm while waiting to be scheduled. Dr Matthew Banks, Consultant Gastroenterologist is of the view that with an already stretched and disillusioned health service, clinician engagement is often lacking and unfortunately targets do become increasingly important. Therefore, if we must focus on targets while remaining patient-centric, perhaps the right question to ask is ‘how do we ensure that patients remain safe while waiting?’ The answer isn’t easily derived but robust clinician engagement is a good place to start.

Dr Banks went on to say “I work in a large and busy tertiary referral cancer centre in central London where I have seen the consequences of a delay in cancer diagnosis on many occasions. This is due to a number of factors including a delay GP referral, as well as a long wait for their initial investigations as there were no ‘red flag’ symptoms’ before referral to our unit. As a result, patients have needed to undergo extensive surgical organ resection with chemotherapy and a poor survival, rather than a curative minimally invasive organ-sparing operation.”

Mr Nabeel Malik, Consultant Ophthalmologist also reports similar experiences. “I have seen where delays in rapid assessment, diagnosis and treatment can have a significant and irreversible impact on patients’ well-being and sight. With the current demographics and disease burden, many ophthalmology departments lack the financial and structural capacity to see sight threatening disease, such as age related macular degeneration, in a timely manner. This can have an irreversible impact on vision. Not only is this a disaster for the individual concerned but this impacts the immediate family and society in general”.

Maintaining the quality of clinical services while burdened by financial constraints will continue to be a challenge for several years. As things currently stand, the picture continues to be alarming (see diagram below). Many providers are still struggling to see their patients for routine care within 18 weeks. The reasons for this is often multifaceted and so it would be idle to suggest that it can easily be remedied. What is needed however, is sustained effort. Those providers who understand this will not be breathing a sigh of relief following Mr Steven’s statement but instead will foresee that continuous lengthening of waiting lists will lead us to only one destination- very unmanageable waiting lists.

Image courtesy of AppSource

In the recent mandate from the Government to NHS England: April 2017 to March 2018, the goal set out is that by 2020, at least 92% of patients on incomplete non-emergency pathways to have been waiting no more than 18 weeks from referral. It is therefore clear that 18 Week RTT is not the urgent priority. The argument as to whether this is illegal is one which the Labour government and legal scholars will continue to have. However, for those of us who deliver clinical services to patients, we would like to make the argument that spiralling waiting lists, while they may no longer have financial consequences for providers, can and do have potentially life altering consequences for patients.

Thankfully, the CQC recognises this and has assured 18 Week Support that they will continue to robustly scrutinise providers and will not be relaxing the “Service is Responsive’ standard. For those providers who choose not to apply sustained effort to tackling 18 Week RTT backlog, they can expect to be found inadequate when their services are judged against this CQC quality standard. It is hoped that the reputational risk of having unmanageable waiting lists, the CQC yardstick, the potential and actual adverse consequences for patients and the continued pressure from interested parties will go some way to prevent a continued worsening of RTT performance.