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Practice comment

Surgery waiting list targets remove choice and penalise services 

  • 1 Comment

The 17 week target will prevent patients from choosing when they have surgery. Staff should be able to use their clinical judgement to meet patients’ needs, says Linda Nazarko  

 

In the past, people needing elective surgery were forced to wait months or even years on NHS waiting lists. Now they should expect to wait no more than 17 weeks, and soon those waiting longer will be entitled to private healthcare. Is this a triumph for consumer choice?

Sometimes targets such as the 17 week waiting list initiative can have unintended consequences and can actually limit choice and potentially penalise services that aim to offer patient choice.

I have been a nurse for 31 years and those years have taken their toll on my feet. Last year I decided to do something about it, and the patient choice initiative enabled me to decide where to have surgery to correct the bunion on my left foot. So far so good; the operation was scheduled and the podiatry surgeon succeeded in making a silk purse out of my sow’s ear of a foot.

I recovered quickly but not as quickly as I would have liked. My foot remained swollen for many months and I wore below knee compression stockings for months to control the foot oedema. The surgeon assured me that this swelling was normal after surgery, but the trouble was that I had another foot that also needed surgery. The surgeon asked me when I would like it done.

The government seems to think that those of us who wait more than 17 weeks are being forced to do so, but sometimes it is a matter of choice. I wanted to give my left foot the chance to completely heal. I knew I would have to put all my weight on it after surgery on my right one.

The care I have received throughout my patient journey has been excellent; all staff have treated me with dignity and respect. I just wish they too could be treated with dignity and respect

I had other reasons for wanting to delay my second operation. I wanted to time it so it would not interfere with my summer holiday since it is not possible to fly for six weeks afterwards, while wounds interfere with swimming and heat exacerbates foot swelling. Also, I did not want to be on crutches over Christmas, and January can be an extremely busy month at work.

I worked out that it would be best for me to have my operation seven months after my initial consultation. However, if the surgeon allowed me to choose when I had my operation the hospital would not meet its targets. This demonstrates how hospital staff who are being truly patient centred can appear on the statistics to be failing patients. Had been a private patient I could have chosen when to have my surgery and could have scheduled it to meet my personal circumstances.

Fortunately there are always ways to circumvent inflexible systems that get in the way of providing good patient care. Unfortunately, circumventing systems is not always the most efficient way to work, but needs must. If the system had been flexible my surgery could have been booked months ago. Staff could plan surgery in advance and patients could be allocated dates that meet their needs, rather than arbitrary targets that actually reduce choice. Instead I must return to the hospital for another outpatient appointment so I can officially go on the waiting list at the right time.

The care I have received throughout my patient journey has been excellent; all staff have treated me with dignity and respect. I just wish they too could be treated with dignity and respect. They should be allowed to use their clinical judgement about when to schedule elective surgery rather than being forced to meet targets that would not be out of place in a factory production line.

LINDA NAZARKO is consultant nurse for older people, Ealing and Harrow Community Services

  • 1 Comment

Readers' comments (1)

  • The Governments '18 week' Referral to Treat target (it's never been a 17 week target!) does NOT prevent patient's from making 'social' choices about when to undergo their surgery i.e. to fit with holidays / care provision / work commitments etc... ) - 'time out' or 'clock pauses' as they are often referred to in this target driven system are perfectly legitimate. These allow the Hospital to 'clock pause' the patient at the 'decision to treat' point. For instance, it may have taken 10 weeks to get from the initial stage of GP referral (clock start) through the appointment process and any required diagnostic investigations / plus followup appointment, to that 'decision to treat' (e.g. surgically) ...the (provider) Hospital is expected to offer the patient a date for their operation within 18 weeks from the clock start (usually initial referral) - however, if the patient declines this offer (inside the 18 weeks target) and chooses to delay and subsequently agrees a later 'TCI' (to come in) / operation date their 'clock' is paused from that initial tci offer date to their actual operation date. The result? patient is 'clock paused at 10 weeks (initial referral) right through to their TCI date, and so although several months may elapse inbetween - they are still treated at 10 weeks (that clock pause point (i.e.adjusted) ... which might have been something more like 30+ weeks if you were to count an 'unadjusted' period - i.e. without the 'clock pause'. So it can be a 'win win' - the Hospital doesn't breach their 18 week target and the Patient has their operation on a date they agree with the Hospital. (Shame that the DoH is also putting pressure on Hospitals to keep their 'clock pause' % rates as low as possible - and allowing patients' such choice has the opposite effect.

    Being medically unfit is treated differently. as under the 'rules' of 18 weeks - patients should not be on a waiting list at all unless they are "fit and ready to proceed"... Should the Hospital do so then their 18 week 'clock' must continue to 'tick' - and risk a 'breach' (which they'll not do willingly due to the financial penalties which might be imposed.).

    Now, Hospitals only go on what the patients tell them, so if a patient merely declares they wish to 'delay' until later in the year - that's fine .... as soon as they declare "I'm getting over another operation, so wish to wait a bit longer", this then puts them in the 'medically unfit category .... and the Hospital must send them back to their GP until 'ready'.

    Whilst this might sound harsh - the truth is that some patients are 'medically unfit' for several years - yet used to still be on a waiting list - be contacted to book a date for their treatment on more than a few occasions, (with an associated administrative cost each time) ... or attend for their treatment only to be sent away again (more costs) ... putting some responsibility back onto the GP and the patient themselves - simply by saying 'get your GP to contact the Hospital (centralised booking service or Consultants secretary) when you are fit/ready to be dated, means that time is not wasted by Hospital staff; and the people who know best - i.e. the patient themselves and their GP, when they are 'fit' to be listed - make the contact is perfectly reasonable - because along with 'choice' comes a degree of patient responsibility. A good 'common sense' approach by the Hospital will ensure that many such patients are not required to go through the outpatient process again, but (according to local protocol) can start where they left off - and be added straight back onto the inpatient waiting list makes this a vastly better overall waiting list management approach.

    Targets aren't all bad - they have made HUGE differences in waiting times - as a Senior Nurse working in service improvement, one who spends considerable time working with auditing patients Referral to Treatment pathways - the inefficiencies in our systems and the simple ways we can change, improve and thus progress to erradicating such inefficiencies is an absolute necessity. Would you willing accept that it might take 3 - 6 weeks for a Hospital to process a referral request to the actual booking of an appointment which was a further 10 weeks into the future??? Well, that was the reality a mere 5 years ago!!

    There are Hospital's around the country who work actively to manage these Government Targets to optimise patient experience whilst endeavouring to also not compromise their own performance management achievements ... the rules are not black and white - and given that there are also some local Patient Access Policy agreements in place which make start, stop and 'pausing' of clocks more complicated still (patient 'availabililty' to attend being a common one) - some to suit patient scenarios (as above) and others which are to help mitigate risk of Hospital's breaching said target when demand for services exceeds capacity ... demands greater understanding amongst clinicans who are part of the Patients Pathway - and who themselves could make a real diifference in improving clinical practice by reducing unnecessary delays .... but Government ministers need to understand how the imposition of such targets and ther requirements for hospitals to meet them is feeding the administrative and bureaucratic costs which we need to reduce.

    But for all the negative comments which are made about 'targets' - since 2003 when patients would commonly wait 17weeks from GP referral to their first hospital appointment - whereas now they are receiving their first definitive treatment (often surgery) inside the same 17 week period - YES... we've come along way - and the driver has been these targets - we wouldn't have had the Chief Excecutive / management commitment or the financial input to achieve this improvement for patients without these 'targets' .....

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