COMMONS

Confidence in hospital trusts meeting waiting time target undermined

29 April 2014

The Public Accounts Committee publishes its 54th report, NHS waiting times for elective care in England

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

"Public confidence in the success hospital trusts have had in meeting the 18 week waiting time target is inevitably undermined by errors in trusts’ recording of waiting time information. Trusts are struggling with a hotchpotch of IT and paper-based systems that are not easily pulled together, which makes it difficult for trusts to track and collate the information needed to manage and record patients’ waiting times.

The National Audit Office reviewed cases at seven trusts, and found that waiting times for nearly a third of cases were not supported by documented evidence, and that a further 26% had at least one error. Waiting list data needs to be independently audited.

The NHS England guidance on the management of waiting times is complex, allowing trusts some flexibility in how they manage patients’ waiting times. There are, however, unintended consequences, such as variations between trusts in the number of cancellations they allow patients to make before referring them back to their GP, thereby restarting the waiting time ‘clock’. These differences reduce the comparability of trusts’ waiting times.

If patients cannot be confident of accurate comparable data on the performance of hospitals they cannot exercise choice. Both GPs and their patients need reliable and comparable information about the waiting time performance of individual trusts so that they can make an informed choice about where to be treated.

Furthermore, patients do not fully understand their rights and responsibilities. It should be a lot easier for patients to interact with hospitals and understand when they will see a consultant, but individual hospital policies on access to treatment are often out of date and not publicly available.

The online Choose and Book appointment system has been underused by both patients and healthcare professionals. We are sceptical about the NHS’s ability to ensure that the replacement system, e-Referrals, will be used any more fully."

Margaret Hodge was speaking as the Committee published its 54th Report of this Session which, on the basis of evidence from the Department of Health, NHS England, Monitor and the NHS Trust Development Authority, examined NHS waiting times for elective care in England.

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 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 simply wrong. Multiple organisations, including trusts themselves, clinical commissioning groups, Monitor, the NHS Trust Development Authority and NHS England have a quality assurance role. However the external audit provided in the past by the Audit Commission has yet to be replaced and the Department acknowledged the need to do so, with regular spot checks being undertaken to ensure accuracy. We are not yet convinced that responsibilities have been clearly defined.

Recommendations

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 produce consistent and reliable data. The data should be audited by someone independent of the trust it relates to.

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, the 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. 

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 understanding how the waiting list for treatment works. Patients do not fully understand their rights and responsibilities– including their right to be treated within 18 weeks. They do not realise that if they cancel or do not attend appointments they may have to wait longer. 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 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 online, which could help the NHS reduce the annual cost of up to £225 million due to patients not attending first outpatient appointments.

NHS England must work with clinical commissioning groups and trusts to make sure that patients are given full information in a clear way about their rights and responsibilities under the NHS Constitution.

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 the clock measuring waiting times starts again. 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.

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.

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 and save costs.  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 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.

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.

Further information

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