Alan Nye on hitting the 18-week target

Richard Lehman Some doctors have been complaining of a targetitis epidemic within the NHS for years. Such world-weariness should not detract from confirmation that the health service in England has achieved its commitment to treat patients within 18 weeks of referral – where clinically appropriate and convenient to the patient.

Five years after the pledge was first made as a central plank in the NHS Plan, we can congratulate and thank clinical, managerial and support staff across primary and secondary care for the dramatic changes in working practices and service design which made this week’s announcement possible.

Of course, there are clinicians who are both wary and weary of centrally-set targets. What the 18 weeks commitment represents is an over-arching theme for the NHS throughout England – faster access to high quality care based on need. Or, to put it another way, an end to unnecessary waits.

Achieving that provides a bedrock for an NHS which can now enjoy increased freedoms to respond to local priorities and which provides patients with choice and control. If targetitis did exist, the delivery of the guarantee of relatively short waits for treatment is the antidote.

Waits are now at their shortest since NHS records began, While we may have highlighted the 18 week guarantee, median waits in January were 8.6 weeks for admitted patients and 4.6 weeks for those not requiring admission to hospital.

Our social research confirms that both the public and clinicians recognise shorter waits are central to the future success and development of the NHS.

Shorter waits mean less worry and stress for patients and their families, as well as the obvious benefit of earlier relief from pain or discomfort. New care pathways allow patients to track their progress and understand more about each stage of the journey from referral to tests, pre-assessment and final treatment.

Those pathways have been developed locally by local health communities, often leading to closer and stronger relationships between primary and secondary care organisations and professionals. They often mean more services are offered in GP practices or other community settings, improving efficiency and making the experience more convenient for the patient.

As I am writing this from Whitehall, readers are doubtless waiting for me to emphasise that the 18 Weeks commitment could not have been met without the increased resources poured into the NHS over recent years. I won’t disappoint you – this could not have been done without additional money.

But the service re-design, overhauled diagnostic procedures and the imagination and enthusiasm of health service clinicians and managers have brought about the revolution which has made the most of the new money. It is in investigations that particularly spectacular progress has been made, notably with MRI and audiology.

The professional organisations have often provided a sterling lead in this. For example, the Royal College of General Practitioners has emphasised to members that the best outcomes are achieved by the patient, GP and specialist all working together to determine the pathway of care.

The Royal College of General Practitioners has reminded members that they can work with secondary care colleagues to improve communication and information sharing – while also improving the booking of hospital appointments and the synchronisation of tests .

Writing this for the BMJ website, I would be naïve to claim that last week’s announcement is confirmation that no part of the English NHS is struggling with waiting times. Similarly, clinicians and other staff might feel that striving to deliver this ultimate target has increased their workload.

To those feeling a touch of cynicism or scepticism, I would conclude with one pledge and one thought based around the social research referred to above. Just as achieving the target in January represents the start – not the end – of this process for local health communities, so it does for the Department of Health and strategic health authorities.

We will continue to provide all the support we can to ensure the performance is sustained. Our website, will continue to provide extensive information and best practice updates on waiting times.

We will also continue to run events: our national coaching programme for orthopaedics – a specialty which has made spectacular progress in reducing waiting times but which is still narrowly short of the target – will continue through 2009.

Evidence suggests that local health communities which have participated in the coaching programme have made more progress than those that have not.

We are also publishing a sustainability toolkit intended to help local health communities maintain the impressive progress they have made.

The social research quoted above suggested that three-quarters of clinicians supported the maximum waiting time; those with positive views cited reasons such as improved clinical outcomes, better synchronisation of treatment and reduced stress for patients.

Patients who receive quality treatment more quickly, and who know what is happening at each stage of their journey along the pathway, are likely to be happier and more relaxed.

In the end, that is surely a state of affairs which will boost your job satisfaction.

Alan Nye is a GP in Oldham, Lancs, and a member of the Department of Health’s 18 Weeks Clinical Advisory Group.

  • Anne Bedish

    Dear Dr Nye,

    I hope you don’t mind me responding to this, I am not a doctor, simply a ‘patient’.

    I believe that the NHS waiting lists have got shorter because more and more people are using the private sector.

    Some twelve years ago I was referred to a consultant at my local private hospital (my family gets Bupa as part of my husband’s work package). In the waiting room there was one other patient, and at subsequent appointments in that period there was only ever one or two other patients in the waiting room. Two years ago I was again referred to this same private hospital and was astonished to find that a new waiting room had been made and that it was practically overflowing with patients ! Some were even having to stand ! And on subsequent appointments the waiting room was always full. It was more crowded than my GP’s waiting room !

    It seems obvious to me that between the first time I went to that hospital and the second there was a HUGE increase in patients. These private patients are not on NHS waiting lists and as a result NHS lists must be shorter.

    Anne Bedish

  • ben

    The increase in capacity has no doubt been a good thing, however blanket targets have not as there is no clinical need built into them. This is the point.

  • Helen

    As a part of the management team in our department, I am 100% behind the 18-weeks to treatment, and the plans for payment by results for NHS departments.

    What I object to is that there has been no extra funding forthcoming for administrative support to collect and record the 18-week wait data.

    Since returning to the NHS 3 years ago, I’ve participated in the roll out of Systm1 – which would be excellent if it was used globally – this joined up system of medical records is a long way from perfect, because there has been no decision to use just one programme.

    A typical uncomplicated patient will take an additional 5-10 minutes of administration time for each patient contact, now we are using Systm1, and from what I have seen of the 18-week data entry, this will increase another 5 minutes per patient contact. This may not seem like much, but I have colleagues with 400 -1000 patients on their workload and those minutes just keep on adding up.

    Band 7 staff like myself are more valuable on the shop floor, than stuck behind a computer desk entering contact data

    Further, with the age range of my colleagues, not all of belong in the computer savvy generation, and I am often receiving tearful and panicked phone calls from my line staff about glitches to the computer system – the risk of stress related absence will only grow with the added pressure of administration for 18-week wait.

    So lets spend money to save money, and provide adequate administrative support. I am sure there are plenty of redundant call-centre and bank people who would be more than willing to be employed entering data as directed by clinicians.


  • ted willis

    18 week targets are great. -for lots of people in lots of offices with lots of computers, no recession for them.

    what about patients?- for most ie non surgical conditions it is irrelevant – what about gps and orthopaedics? take a patient i referred recently to an orthopod with a very good local reputation. he rang me becuase he had gone away for the weekend and arrived back to find an appointment letter posted 2 days earlier for an appointment that day. ok he thought – i will ring and change it. Oh no – you have to get a new referral letter from your gp. i ring the hospital – ‘we cant change the appointment – otherwise it will be more than 5 weeks since the referral and that is a ‘breach’. so new letter gets sent off – a bit more work for me and my staff and a few phone calls and some hassle for the patient – but the hospital might hit the target – so thats alright thenl