In August, Jeremy Hunt announced a ‘managed breach’ of two shorter-term (18 week) treatment waiting time targets: the expectation that 90% of inpatient and 95% of outpatient treatments started within 18 weeks of referral. His argument was that this relaxation would give hospitals breathing space to treat people who’ve been waiting the longest (over 52 weeks). They had until December 2014 to sort it out.
At the time the relaxation was announced, this applied to 490 people in England – a tiny 0.02% at the tail end of the treatment waiting list. In the same month, there were over 210,000 people who’d been waiting over 18 weeks and 63,000 of these had been waiting over 26 weeks.
We don’t yet have the December data, but November’s was just published yesterday. This gives us a pretty good indication already of how effective this managed breach has been. So let’s take a moment away from panicking about A&E and explore how this amnesty is playing out.
Spoiler alert: the number of long waiters is barely down, and in the meanwhile the inpatient target has further deteriorated and the outpatient target has been breached for the first time since 2008.
Are long waiters better off?
At first glance, yes. The number of people on the treatment waiting list who have been there longer than 52 weeks has been consistently low for a long time, noticeably since the zero tolerance policy was introduced in April 2013. In November, 362 people had been waiting more than 52 weeks, a fall of 128 people since August. Good news, but not the eradication we’d been hoping for.
Figure 1 shows the number of long waiters by month for the last year who’ve been treated.
Before the relaxation, the NHS was treating around 500 people per month who had been waiting more than 52 weeks, and the total number left waiting was slowly decreasing. If the relaxation were having the desired effects, what we would expect to see in the most recent data is an increase in the number of inpatient and outpatient treatments happening over 52 weeks, and a dramatic reduction in people still waiting more than 52 weeks.
In fact, what we see is that the number of inpatient and outpatient treatments for people over 52 weeks has gone down.
That suggests there is a small number of people who cannot be treated, either because there’s a genuine clinical reason for the delay but their clock has not been stopped, or they are simply ‘ghost’ patients due to data issues. Better information about the list should reveal this. Of course we also have missing trust data to contend with throughout all of this, which makes it even more difficult to figure out what’s really happening.
In summary, unfortunately, it doesn’t appear that there has been an increase in treating people who’ve been waiting the longest – the main goal of this managed breach.
What has happened to everyone else?
Let’s now go beyond these long waiters and consider what has happened to everyone else waiting for treatment during this time:
- As ‘planned’, 18-week targets were being breached, and in November things were particularly bad. 87.5% of inpatients started treatment within 18 weeks (compared to a 90% target) and 94.8% for outpatients started treatment within 18 weeks (compared to a 95% target). These are the lowest figures we’ve seen since 2008, and the first time the outpatient figure has missed its target under the current government. Figure 2 shows these changes.
- The overall size of the waiting list has decreased slightly to 2.99 million people (this compares to 3.09 million people in August). However, this is following a typical seasonal pattern so is unlikely to be due to improved performance.
- Despite this seasonal respite and ongoing NHS activity (the number of inpatient and outpatient treatments conducted) over the last four months, these are far outweighed by the growth in the number of people waiting. We would expect to see a marked increase in activity to meet these changes that just isn’t there.
December: the month of future past
We don’t yet know the fate of these figures in December. But data from previous years indicate that activity generally slows during that month. Given this and given the troubles we’ve been hearing about in A&E, I would be surprised if there was a sudden change from current trends.
Although we haven’t heard anything specific from the minister, in principle the targets should be back in effect with the start of the new year. In my view, that’s a good thing. We need to make sure that the system is working for the majority of those seeking care, not just the most extreme cases.
Dorning H (2015) 'The tail of the long waiters' Nuffield Trust comment, 16 January 2015. https://www.nuffieldtrust.org.uk/news-item/the-tail-of-the-long-waiters