We'll have to wait and see what Hunt's waiting time intentions will bring

The current governmental flap over elective waiting times is so fascinating, so contorted, and yet so familiar that it is hard to know where to begin. So let’s start with the story so far.

Back in November 2011, then health secretary Andrew Lansley announced a new waiting times target: that 92 per cent of the waiting list - “incomplete pathways” - must be below 18 weeks.

‘The DH said that “those who waited over 18 weeks must not be forgotten”, and quite rightly too’

Why? Because the existing waiting times targets penalised hospitals for treating their long waiting patients, and some trusts were happily achieving the targets even if they had many patients waiting over a year.

Long waiters were finding themselves stranded on the wrong side of 18 weeks; hospitals had no incentive to treat them, and were even fined if they did.

Mr Lansley’s new target would put an end to all that. Instead, hospitals would be penalised for having long waiters on their waiting lists, not for treating them.

The Department of Health said around the time that “those who have already waited over 18 weeks must not be forgotten”, and quite rightly too.

• Hunt: care targets to suffer ‘managed breach’
• Training and development: The 18 week waiting game
• Findlay: 18 week waits, May 2014 - explore the maps
• More waiting time analysis from Rob Findlay

Slow and steady

What happened next was… nothing.

For a whole year, Mr Lansley’s announcement remained unimplemented. The new target was only written into the NHS contract a year later, after a muddled drafting process that initially missed it out altogether, then included it with little weight, and finally gave it pole position among the 18-week standards.

‘NHS England undid much of the good work in the next NHS contract’

Incomplete pathways had 50 penalty weightings, ahead of 37.5 per cent for “admitted”. At last, it seemed that still waiting patients were getting the protection they deserved, and the perverse penalties for treating them were on the way out.

In an intriguing case of corporate amnesia following trauma, NHS England - which had been split from the DH around then - promptly undid much of that good work in the next NHS contract.

Penalties for admitting long waiters were raised to £400 per breach, against only £100 for each incomplete pathway long waiter still on the waiting list.

Those new penalties came into force this April, and they set the scene for what is happening now.

Breaching point

Also in April, NHS England released data showing that the “adjusted admitted” target had been breached for the first time in three years.

The breach was not entirely unexpected; the English waiting list had been growing for some time, and was reaching the point where this 18 weeks target - the toughest of the three - becomes hard to sustain.

‘A national waiting list initiative was born, with all the classic ingredients’

Even though they were increasing the penalties for admitting long waiters, NHS England now encouraged trusts to admit their long waiters, saying that tackling waiting times “means treating those who have waited the longest, which may mean that we miss the standard”.

And so a national waiting list initiative was born, with all the classic ingredients:

• a modest but credible lump of one-off funding to patch a long term problem;
• unreasonably short deadlines - and during the holiday season too; and
• a focus on the long waiting tail of the waiting list - and seasoned observers know that these tails grow back.

NHS England allowed trusts to breach the admitted patient target up to the end of August, though bizarrely it seems they did not pass this message on to clinical commissioning groups because many are continuing to apply the newly beefed up contract penalties.

Hunt takes a swipe

Which brings us to health secretary Jeremy Hunt’s speech today. He rightly credits the last government with achieving 18 weeks, and his government with sustaining it.

He takes a welcome swipe at the admitted patients target when he says “a target intended to do the right thing ended up incentivising precisely the wrong thing”.

And he rightly presses for the NHS to abolish one year waits as closely as possible.

And then he says this: “The truth is we need to ensure both that 90 per cent of people get their treatment within 18 weeks - the official target - and that people who are not treated within that period are not neglected. So I have set a timeframe of this calendar year to deliver on both of those objectives.”

‘If everything goes according to plan, the extra money will stop waiting lists growing this year’

So if everything goes according to plan, this is how it pans out. The extra money will stop waiting lists from growing this year so that all targets are sustainable.

Trusts will not be caught by the perverse target incentives, because they only kick in if there are lots of long waiters on the list and those will be cleared. So September’s performance will be good, and when the data is released in November he can claim an early success.

Alternatively, this is how it could go pear shaped. The NHS will be unable to clear its backlogs at short notice while everyone is on holiday.

The waiting list will grow until the admitted patient target is unsustainable, forcing managers to treat fewer long waiters when the target is enforced again in September. So patients will be left stranded on the wrong side of 18 weeks, and eventually the more serious incomplete pathways target will give way.

Or will it be a muddle through the middle? Whatever happens, we live in interesting waiting times.

Rob Findlay is founder of Gooroo and a specialist in waiting time dynamics