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hospital policies on access to treatment are often out of date and not publicly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