Select Committee on Public Accounts Forty-Fifth Report


FORTY-FIFTH REPORT


The Committee of Public Accounts has agreed to the following Report:

INPATIENT AND OUTPATIENT WAITING IN THE NHS

INTRODUCTION AND LIST OF CONCLUSIONS AND RECOMMENDATIONS

1. At 31 March 2002 some 195,000 people in England had been waiting over 13 weeks for an outpatient appointment and 1,035,000 were waiting for treatment. Waiting a long time can be a painful experience, and over a third of patients have stated that their condition worsened while waiting.[1]

2. On the basis of a Report by the Comptroller and Auditor General,[2] we looked at progress in reducing waiting lists and waiting time, ways of improving performance and steps being taken to give patients better information and choice on where to be treated. We have also taken into account the Government's latest plans for the Health Service, set out in Delivering the NHS Plan published in April 2002.[3]

3. In the light of this examination, the Committee draws the following conclusions.

  • Reductions in waiting lists and waiting times require concerted action on the main challenges facing the NHS. These include the number of staff, hospital capacity, the availability of effective patient administration systems, the working practices and referral arrangements of consultants and general practitioners and the need for more effective partnership between the NHS and social care sectors in planning patient discharge, particularly for older people.

  • The increased expenditure announced in the 2002 budget and the wide-ranging changes described in Delivering the NHS Plan,[4] seek to tackle all of these issues. In addition to more money, success requires changes in culture and working practice amongst all medical professionals, and increased partnership working and between health and social care. We plan to track progress.

  • Key to the changes is the plan to provide patients with accurate information on the performance of NHS trusts and waiting times, and give them and their general practitioners a real choice over where to go for examination and treatment.

On progress in reducing waiting lists and waiting time

  • On published figures, the Department of Health are making steady progress in reducing waiting lists and waiting times for outpatients and inpatients. But there remains some uncertainty about the accuracy of the figures, partly because not all hospitals validate their waiting lists often enough and because there have been at least ten cases where hospitals have made inappropriate adjustments to their waiting lists in order to keep reported numbers down. We are reporting separately on these ten cases.

  • To the patient, the primary concern is the total time they wait from seeing their general practitioner to treatment. The NHS currently only measures this for cancer, although they plan to do so for other serious conditions where they implement National Service Frameworks and there are clear co-ordinated pathways of care. This would clearly be desirable. There are substantial numbers of patients waiting for tests or further examinations who are currently not captured in the statistics and a risk that many of them might suffer undue delays in the process. The NHS should monitor the numbers and length of times involved, so that managers are fully aware of any hidden backlogs.

  • The pressure to reduce waiting lists has led a significant number of consultants to treat some patients before others with higher clinical priority. The challenging targets for waiting times set in Delivering the NHS Plan[5] can only increase this pressure. Although the Department has issued clear guidance that clinical priorities must be adhered to, they should supplement this guidance with annual surveys of consultants to assess whether it is being observed.

On ways of improving performance

  • One key to reducing waiting times is increasing the capacity of the NHS. The plans announced in Delivering the NHS Plan,[6] should go a long way to increasing skilled staff resources and providing more beds. The Department's review of the system for allocating resources is also important, in view of the significant variations in waiting lists and times in different parts of the country, and in different specialisms. The Department should complete this review quickly and publish the results with any action they plan to take.

  • As the Committee of Public Accounts said in its Report, Inpatient Admission, Bed Management and Patient Discharge in NHS Acute Hospitals,[7] the NHS needed to develop modern patient administration systems, appoint discharge co-ordinators, and achieve closer co-operation between hospitals, general practitioners and social services departments. All of these issues are now being taken forward. However, it is important to monitor the use of this money so that it is spent effectively on tackling delayed discharges and bed blocking, including the expansion of intermediate care, and does not merely feed through in higher costs, for example for places in care homes.

  • The Department are making strides in introducing best practice, including experience from overseas. There are already examples of good practice, for example in developing protocols between general practitioners and trusts for referrals to hospitals. Success will require effective transfer of best practice across the NHS, through for example the NHS Modernisation Agency. It also requires the active involvement of clinicians and general practitioners, and the Department needs to bring to an early conclusion their negotiations on the new consultant contract, and their discussions with royal colleges on new working practices, including different groups of staff undertaking work traditionally done by doctors.

  • In areas and specialties where waiting lists and times are high, there is a risk that the use of NHS facilities for private healthcare may mean NHS patients waiting too long or other patients being treated ahead of the clinical priority. On the other hand, private use of NHS facilities can generate extra income for NHS use and help retain top clinicians in the NHS. NHS Trusts should monitor this balance closely, and be ready to act where NHS waiting lists and times are long.



On steps being taken to give patients better information and choice on where to be treated

  • Patients and their general practitioners are tied to their local NHS Trusts, when other hospitals, often only a few miles away, may have lower waiting times. The proposals in Delivering the NHS Plan[8] to provide information on waiting times and performance and to introduce greater choice, starting with patients with the most serious conditions, is a positive step. We expect the new Strategic Health Authorities, with their larger catchment areas, to work with Primary Care Trusts to develop more flexible commissioning arrangements within their areas, to provide all patients with greater choice locally.

PROGRESS IN REDUCING WAITING LISTS AND WAITING TIME

4. Since the creation of the National Health Service in 1948, most people who need to see a consultant or who require surgery but are not emergency cases have had to wait. The total time a patient waits for treatment, from the date the general practitioner refers the patient to a consultant until the patient is admitted to hospital comprises three main elements:

Figure 1: The number of outpatients waiting over 13 weeks


Year (at 31 March)

The diagram shows the number of outpatients waiting over 13 weeks for an initial clinic appointment with a consultant between 31 March 1995 and 31 March 2002

Source: Department of Health

Figure 2: The number of NHS inpatients waiting each financial year end



Inpatient waiting list (thousands of people)

Year (at 31 March)

The diagram shows the number of NHS inpatients between the years ending 31 March 1995 and 31 March 2002

Source: Department of Health


5. The Department focus measurement on the outpatient and inpatient lists because these are two distinct elements in the process. The time taken to establish whether surgery is required can involve a range of tests and examinations, and admission to hospital may not be required. However, where there is a clear co-ordinated patient pathway through the system the NHS are measuring time from urgent referral to treatment. For example, the NHS brought in a target of one month between urgent referral and treatment for children's cancer, and one month from diagnosis to treatment for breast cancer from December 2001. They expect to adopt similar arrangements for areas where they have developed National Service Frameworks, for example coronary heart disease.[11]

6. The NHS has shifted its focus from reducing the numbers on waiting lists to reducing waiting times, especially for the most seriously ill patients. In Delivering the NHS Plan,[12] published in April 2002, they set new targets for reducing waiting times for outpatients and inpatients, plus waits to see a general practitioner and in Accident & Emergency departments (Figure 3). However, they remain interested in waiting lists, since reducing them will also bring waiting times down.[13]

Figure 3: Current targets for reducing waiting times, set in Delivering the NHS Plan published in April 2002
By 2004A reduction in waiting to see a general practitioner, so that patients are seen within 48 hours or seen by another primary care professional within 24 hours.
By 2004A reduction in maximum waiting times in Accident & Emergency Departments to 4 hours with average waits reduced to 75 minutes.
By 2005A reduction in waiting times for an outpatient appointment to a maximum of 3 months.
By 2005 and 2008A reduction in the maximum wait for treatment to 6 months by 2005, then falling to 3 months by 2008 (with an average wait of half this time).


7. Although the published statistics show that the Department of Health are making steady progress in reducing waiting lists and waiting times for outpatients and inpatients, there remains some uncertainty about the accuracy of the figures. This is partly because not all hospitals validate their waiting lists often enough.[14] It is also because there have been at least ten cases where hospitals have made inappropriate adjustments to their waiting lists in order to keep reported numbers down.[15] We are reporting separately on these ten cases.

8. Despite progress in reducing waiting lists, there remain wide variations across the country. The Comptroller and Auditor General found that the number of inpatients waiting per 1000 head of population varied between 23.7 in the North West Region and 15.8 in the West Midlands, while the North West Region had the highest number of outpatients (7.2) compared with 3.8 in the West Midlands. He also found significant variations across three specialties, Ear, Nose and Throat; Trauma and Orthopaedics; and Urology.[16]

9. The Department identified three main causes of regional variations;

    —  Capacity constraints in some parts of the country. For example, the facilities available for treating coronary heart disease are much greater in the south of England than in the north, and in specific areas, such as North Staffordshire there is serious under-capacity in acute facilities and at the Mayday Hospital in Croydon, significant capacity shortages around orthopaedics;

    —  Emergency pressures can reduce the beds available for elective surgery, as can delayed transfers of patients to other forms of care;

    —  Difference in the ways NHS Trusts manage their healthcare systems.

10. The NHS has to tackle each of these issues, for example through new resources and by identifying and disseminating best practice. There is also an extensive study being undertaken into the funding formula the Department use to allocate resources across the country, to see whether change is needed.[17]

11. The Comptroller and Auditor General surveyed 600 consultants in three specialities—Trauma and Orthopaedics, Urology and Ear, Nose and Throat. Fifty two per cent of the 558 consultants who responded considered that working to meet the waiting list targets meant they had to treat patients in a different order to their clinical priorities, and 20 per cent said this occurred frequently.[18] A number of other organisations, including the British Medical Association and the Kings Fund have also drawn attention to this issue. The Department doubt whether the problem is as widespread as this survey suggested, partly because there are particular problems in these specialties. However, they have made it clear consistently that clinical standards or priorities should not be compromised. Moreover, the National Service Frameworks now provide a strong driver to give priority to the most serious conditions, such as cancer and coronary heart disease.[19]

WAYS OF IMPROVING PERFORMANCE

12. Waiting lists are influenced by a wide range of factors (Figure 4), and reducing them requires concerted action across many of the key areas of the NHS. We looked specifically at: progress in identifying and spreading best practice; action to overcome capacity problems, including staffing and bed blocking; managing GP referrals; and changing consultants' working practices.

Figure 4: Factors influencing waiting lists


Source: Department of Health

(a) Progress in identifying and spreading best practice

13. The Department have taken a range of steps to identify and spread good practice (Figure 5). This is the key role of the NHS Modernisation Agency, and within it the National Patients Access Team. Securing improvements in practice requires not only clear policies and procedures, but strong clinical involvement with them. The Modernisation Agency has service improvement managers working on a regional basis with local trusts, and teams tackling specific problems, for example in outpatients, operating theatres and pre-operative assessments. They have also run a learning centre for 11 trusts, which had most difficulty in terms of outpatients, and three of those have moved into the top quarter on performance.[20]

14. In addition there is a considerable programme, which includes research and development work, to consider what is happening overseas and how it can be applied to the United Kingdom. The Modernisation Agency has strong links with other health care organisations in Europe, the United States, Australia and New Zealand. For example, there are interesting developments in Norway and Denmark on the information provided to general practitioners on waiting times for inpatient appointments.[21]

Figure 5: The Department of Health's initiatives to improve waiting lists and waiting times
1998-99 to 2000-01Provided an additional £737 million to NHS trusts to reducing waiting lists.
From 2000Action to reduce variation, for example Action on Cataracts, Action on ENT, Action on Orthopaedics, and the Cancer Services Collaborative.
2000-2002The Coronary Heart Disease Collaborative.
Ongoing Guidance on best practice, including to trusts on how to manage waiting lists and how to treat patients within the new shorter maximum waiting times.
  Implementation of a National Booked Admissions Programme by 31 December 2005.
By 2004 20 new diagnostic and treatment centres.
By 31/12/05All patients in any part of the country will be able to choose where their treatment takes place.


(b) Tackling capacity problems

15. The Department see the availability of staff, particularly ancillary staff and nurses, as one of the biggest factors in addressing waiting lists. The Department are now arranging for a substantial increase in staffing so that by 2008 there will be 15,000 more general practitioners and consultants, 30,000 more therapists and scientists, and 35,000 more nurses, midwives and health visitors.[22]

16. The second major factor is the availability of beds. In its Report, Inpatient Admission, Bed Management and Patient Discharge in NHS Acute Hospitals,[23] the Committee of Public Accounts looked at how patient admission and bed management might be improved, including how to develop better collaboration between NHS agencies and social services departments in the discharge of patients from hospitals. The Committee's recommendations included the need for improved planning of inpatient admissions and bed management, and the development of modern patient administration systems. The Committee also called for the identification and dissemination of good practice, the appointment of discharge co-ordinators and closer co-operation between hospitals, general practitioners and social services departments.[24]

17. Through the National Service Frameworks for major diseases, such as coronary heart disease and cancer, the Department are now identifying the levels of treatment needed in different areas, including capacity shortfalls. They have a programme of introducing new electronic patient records across the country by 2005, and are working with 12 trusts on a pilot basis as part of their waiting and booking information systems project.[25] In addition, more elective surgery will take place in new free standing surgical units or diagnostic and treatment centres: there will be 750 primary care one-stop centres around the country; and hospital capacity (currently around 135,000 beds) is likely to grow by at least 10,000 more general and acute beds.[26]

18. Since our hearing, the Government have announced a range of actions and plans to tackle delayed discharges and bed blocking, especially by older people. This includes plans to expand intermediate care by about 30 per cent by 2005-06.

19. In 2001, for the first time, the Department required local councils to produce a three year strategy for building capacity and partnerships in residential and home care in agreement with local health services and the private sector. The Department are analysing this. They are also spending an additional £300 million on social services—£100 million in 2001-02 and £200 million in 2002-03, on the understanding that they spend it alongside health and that they use flexibilities available under the Health Act 1999 - for example joint budgets and joint management - to do that.[27]

(c) Managing GP referrals

20. A consultant relies on the judgement and experience of general practitioners to help decide how quickly to bring an outpatient into a clinic. But a general practitioner deals with a variety of symptoms and ailments each day and, unlike the consultant, does not specialise in one area of medicine. As a consequence, general practitioners' referral practices vary widely. The Royal College of General Practitioners has concluded that much of this is a result of geographical variation in patient need and affluence, characteristics of referring doctors and organisational factors of individual general practices.[28]

21. The Comptroller and Auditor General's survey of consultants in the urology, orthopaedics and ear nose and throat specialties identified concerns about the number of inappropriate referrals from general practitioners. The mean proportion of "inappropriate" referrals between the three specialties was 25 to 29 per cent. However 40 consultants thought the percentage was over 80 per cent.[29]

22. The involvement of general practitioners is crucial to progress, because from the patient's point of view it is the whole process, the whole patient journey, that they want to see improved.[30] There are, however, cultural issues to be resolved, for example by reducing referrals to specific consultants and pooling referrals to avoid lengthy waits to see particular consultants, unless there are sub-specialty reasons. This needs to be embedded into people's behaviour, and the Department are encouraging general practitioners and consultants to draw up referral protocols, and for them to work together with hospital managers and primary care trusts to plan the system in a way that works. This includes identifying cases where the referral should be to specialists other than consultants, for example referrals to physiotherapists in orthopaedic cases, and in some cases cash incentives to encourage general practitioners to introduce better referral practices.[31]

23. Trusts and health authorities have developed over 850 separate referral protocols. One trust alone has developed 126. Many trusts and health authorities have developed similar protocols on common topics such as breast cancer and screening. The National Patients Access Team commenced a project in April 2000 to collate existing referral protocols from trusts. Protocols have also been developed as part of the Cancer Services Collaborative, and work is ongoing to introduce referral advisors in every Primary Care Group. The Modernisation Agency is also developing referral guidelines as an integral part of its modernisation programme. In addition, by April 2001every general practitioner, primary care group and trust has been required to put in place systems to monitor referral rates, and the Department will be able to review the position in 2002.[32]

24. There are barriers which stop general practitioners referring patients to trusts outside their Health Authority area - through "out of area treatments", even to trusts close by where waiting times are much shorter. These include the agreements between Health Authorities and NHS Trusts on planning and paying for care, which mean that Health Authorities committed to send their patients to specific trusts, which in turn enabled those trusts to plan their resources. The new primary care trusts can change their commissioning arrangements year on year, making decisions closer to patients, but the Department are looking at ways of introducing greater flexibility and choice within the system.[33]

(d) Changing consultants' working practices

25. One of the barriers to tackling waiting lists is the history and culture of the NHS. The Department believe that doctors are very good at moving forwards on clinical practice, but less good on some of the management practice issues. They have set up the NHS Leadership Centre, because really good leaders are essential if change is to happen. Getting best practice transferred across the NHS, requires strong involvement of clinicians and the Modernisation Agency is bringing consultants together to look at how they manage their lists.[34]

26. There are over 20,000 consultants in the NHS, many of them part time. Full-time consultants are allowed to do private work up to 10 per cent of salary and this is monitored by NHS trusts. For those who are part-time, there is no limit to private work but the consultants have to meet their commitment to NHS trusts for agreed sessions. The Department pointed to studies that show that the vast majority of doctors, part-time or full time, work longer that their contracted hours. At the same time, in 1999-2000 almost 7,000 beds were taken up by private operations in the NHS. These patients may be treated outside their normal clinical priority, thereby adding to waiting lists. On the other hand, private use of beds and facilities produces additional revenue to hospitals, which can be spent on patient care.[35]

27. There are a number of initiatives and actions looking at the way consultants work. For example, the Department are negotiating a new consultants' contract, including issues such as productivity and workload. They are also engaged in discussions with the royal colleges about new standards that might increase the time clinicians spend with patients, on ways of working differently and on different groups of staff undertaking work traditionally done by doctors. In Delivering the NHS Plan,[36] the Government announced initiatives to develop the role of therapists and nurses, and new training opportunities for staff through a NHS University, which will start work in 2003.[37]

STEPS BEING TAKEN TO GIVE PATIENTS BETTER INFORMATION AND CHOICE ON WHERE TO BE TREATED

28. The Department of Health recognise the importance of keeping patients informed about the time they can expect to spend on a waiting list, and the national booked admissions system is crucial to this. In its Report, Inpatient Admissions, Bed Management and Patient Discharge in NHS Acute Hospitals, the Committee of Public Accounts saw the introduction of the system as a way of reducing unnecessary cancellations for medical reasons or because patients do not turn up. Since 1998-99, the Department has made £65 million available to support this programme, and allocated a further £50 million in 2001-02. By 31 March 2002, five million patients a year will be in booked admission systems and there will be fully integrated booking by 2005. One example of progress so far is Kings College Hospital NHS Trust in London, where 24 general practices are linked in electronically, three quarters of all their appointments are booked electronically, and what used to take weeks now happens in a matter of minutes.[38]

29. There are initiatives in other countries to ensure that patients are kept well informed about waiting times. For example in Denmark, waiting times for each hospital for 25 common medical problems are available on the internet, including maximum waiting times for patients on both the outpatient and inpatient waiting list. In Norway, patients can review on the internet waiting times for elective surgery at each hospital before deciding where to be treated. From January 2001 patients have had free choice of hospital, and the Norwegian Patient Register is developing an internet information system which will show waiting times at individual hospitals for specific treatments.[39]

30. The Department told us that the NHS Plan had been set up to design a service around the patient, shifting from a producer to a customer focus. Ministers wished to see how the NHS could improve choice within the service in a controlled way, and the Department believe that over time patients will be much more in control. They are introducing greater choice in cancer and maternity. The evidence from abroad showed that where people have the information, change had happened because of the new pressure and dynamic in the system.[40]

31. In Delivering the NHS Plan, the Government announced arrangements to introduce greater patient choice, drawing on practice in Scandinavia, and starting with patients with the most serious clinical conditions. For example, from summer 2002 patients who have been waiting six months for a heart operation will be able to choose from a range of alternative providers, public or private, who have the capacity to deliver quicker treatment.[41]

32. The Department will also publish on the internet and elsewhere regularly-updated information on waiting for all major treatments at all providers. By 2005, the aim is that all patients and general practitioners will not only be able to book appointments at both a time and a place that is convenient to the patient, but compare waiting times in different hospitals and have access to independently validated information on the availability, quality and performance of local health services.[42]


1   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), paras 1-2; Q53 Back

2   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02) Back

3   Delivering the NHS Plan, Cm 5503 Back

4   ibid Back

5   Delivering the NHS Plan, Cm 5503 Back

6   ibid Back

7   1st Report from the Committee of Public Accounts, Inpatient Admission, Bed Management and Patient Discharge in NHS Acute Hospitals (HC 135, Session 2000-01) Back

8   Delivering the NHS Plan, Cm 5503 Back

9   C&AG's Report, para 6 Back

10   ibid, paras 1.1, 2.2-2.7 and Figures 5, 6; Qs 36-42 Back

11   Qs 3-4, 91 Back

12   Delivering the NHS Plan, Cm 5503 Back

13   ibid Back

14   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), paras 8, 2.25-2.28  Back

15   C&AG's Report, Inappropriate adjustments to NHS Waiting Lists (HC 452, Session 2001-02)  Back

16   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), paras 2.8-2.13 and Figures 8-10  Back

17   Qs 5-7, 88, 108-112, 150-154; Ev 24 Back

18   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), para 2.22 Back

19   Qs 9-10, 49-54, 68-71, 93-98, 186-189 Back

20   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), paras 1.14-1.16; Qs 8, 11, 135-136 Back

21   Qs 8, 11, 15, 146 Back

22   Qs 79, 125-126, 202-210; Delivering the NHS Plan, para 6 and Chapter 3, (Cm 5503) Back

23   1st Report from the Committee of Public Accounts, Inpatient Admission, Bed Management and Patient Discharge in NHS Acute Hospitals (HC 135, Session 2000-01) Back

24   ibid Back

25   Qs 8, 134 Back

26   Q158; Delivering the NHS Plan, para 6 and Chapter 3 (Cm 5503) Back

27   Qs 80-85, 148, 211-212 Back

28   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), para 3.5 Back

29   ibid, para 3.6 Back

30   ibid, paras 3.12-3.13 Back

31   Qs 12-13, 43-48, 103-109, 155-156, 169-181 Back

32   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), para 3.9; Qs 169-170 Back

33   Qs 43-48, 127-131, 213-214  Back

34   Qs 11, 16-18  Back

35   Qs 22-35, 194-204  Back

36   Delivering the NHS Plan, Cm 5503 Back

37   Qs 18-21, 86-87, 115-119; Delivering the NHS Plan, para 15 and Chapter 9 (Cm 5503) Back

38   1st Report from the Committee of Public Accounts, Inpatient Admission, Bed Management and Patient Discharge in NHS Acute Hospitals (HC 135, Session 2000-01); C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02) paras 3.32-3.37; Qs 15, 77-78, 160-162, 190, 215-218 Back

39   C&AG's Report, Inpatient and outpatient waiting in the NHS (HC 221, Session 2001-02), paras 14-16, 3.28-3.31; Qs 15, 140-143 Back

40   Qs 46, 60-62, 72-73, 147, 163-165, 185  Back

41   Delivering the NHS Plan, para 10 and Chapter 5 (Cm 5503) Back

42   ibid, para 10 and Chapter 5 (Cm 5503) Back


 
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Prepared 18 September 2002