The pros of waiting time targets outweigh the cons

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Rob Findlay’s article on reforming the waiting times targets demonstrates how difficult it is to design incentives without creating undesirable trade-offs, writes John Appleby

As the Kings Fund’s new report confirms the financial pressure facing the NHS, Rob Findlay’s suggestion to review and change waiting time targets gives us a chance to consider their effects, positive and negative.

John Appleby

‘There is a perverse incentive not to treat patients who have waited longer than 18 weeks’

The role of “targets and terror” in driving down very long waiting times in the English NHS shouldn’t be underestimated, as Dixon, Mays and Jones’ review of NHS reforms between 2000 and 2010 confirmed. They clearly contributed to the 2010 record public satisfaction with NHS performance. Call them standards or targets: waiting metrics are here to stay.

There is a risk of overplaying the perversity of the 90 per cent and other referral-to-treatment targets, and certainly of giving them insufficient credit for bringing down and maintaining shorter waits.

However, they certainly aren’t perfect. There is, or has been, a perverse incentive not to treat patients who have waited longer than 18 weeks, as in doing so they add to number of breaches.

Mr Findlay has rightly made a significant point of this, and we now have the 92 per cent target for patients “still waiting” to try to deal with it.

Lack of urgency

But as his article demonstrates, it’s hard to design incentives without creating other undesirable trade-offs. He argues for essentially scrapping all but the “still waiting” target, and for zero tolerance of 52-week-plus waits. If these were introduced, my bet would be on more unanticipated perversities arising, with more rules and possibly more targets to deal with them (as in the past).

‘The idea that long waits should be treated first is not how waiting lists do or should work’

That’s not necessarily a bad thing, but the suggestion is not likely to be cost free.

The idea that long waits should be treated first is not how waiting lists do or should work. As Mr Findlay knows, long waits are correlated with lack of urgency. He’s surely not suggesting a strict “first come, first served” approach?

So, who gets taken off the list? And when is not just a matter of how long they have been waiting? That makes managing lists difficult.

Professor John Appleby is chief economist at the King’s Fund