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30th October 2023

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News and comment from

Roy Lilley

What matters...


Go with me on this.

I’m thinking on my feet. Well, actually, on my backside as I’m sitting, typing… my definition of multi-tasking.

The big-brains at the Health Foundaton have produced a report on waiting lists.

With respect to their great stature and standing, a citadel where I suspect the cleaners have a higher IQ than wot-I-do…

...I’m not sure the report adds anything to the price of chips… or for that matter, understanding waiting times.

In terms, the report says; if pigs could fly, bacon would be a lot more expensive. Fair enough, it would. 

The authors created a report using scenarios… hypotheticals. Made-up numbers, and it's a grim fairy tale.

I’m not a fan. Scenarios rely on a linear extrapolation. Projecting what’s happening now, into the future.

The Health Foundation try to overcome this weakness by creating three hypotheticals. 

Launching us into the world of an even grimmer ‘what-if’. The one big ‘what-if’ they miss is the inevitable change of government, very likely in the next 300 days.

There’s a cute gimmick that lets you create your own scenario.

Putting all this aside and reverting to the fair minded, charitable, cuddly soul that I am… resisting the urge to put the report in the shredder, along with last week's tips from the Sporting Life...

... let me try and stumble my way through the undergrowth of waiting lists…

… they’re calculated using a baseline of the number of people who pitch-up, in front of a GP who is baffled, cautious, inquisitive, or has a good idea of what’s wrong but still sends the luckless soul off to the hospital.

There starts ‘the patient pathway’. The clock is ticking. Various timelines and way-markers become ‘targets’ … now, mostly missed. 

A typical patient wants five things;

  1. Get in,
  2. Get diagnosed,
  3. Get fixed up,
  4. Get out,
  5. Get on with their lives.

The reality...

Diagnostics - where, actually there hides ‘hidden waiting lists’. For example, longer for an ultrasound than for a colonoscopy. 

In January 2022, the median wait for a diagnostic was 3.1 weeks… very misleading as the proportion of people waiting over 6 weeks for an ultrasound is 26%. Others much longer. Meaning… 

…waiting times will vary. 

Results. Labs, can be quick. Radiology takes longer as there are 33% vacancies in qualified staff to read images and write reports. Meaning…  

…waiting times will vary.

See a consultant or health care professional. How soon? Depends on what you've got. Orthopaedics has the longest wait. Cardiothoracic surgery one of the shortest. Meaning…

…waiting times will vary.

Decision to treat or ‘watch-n-wait’. For routine, non-urgent conditions 92% of treatments should start within 18 weeks of referral. The reality is around 70-odd%. Meaning, 7 out of ten patients will be seen on time. Meaning… 

…waiting times will vary.

Actual treatment… at last! Well, maybe… if there are no strikes. Between March and October, 213,000 fewer patient-pathways have been completed. Where and at what stage they've been paused? Dunno.

... waiting times will vary.

Here’s another problem…

... the number of referrals has recently exceeded their pre-pandemic level. Growing faster than before the pandemic. Meaning… 

The NHS is running up the down escalator.

Headlines; ‘waiting lists head for 8m’… tell us nothing and invite fairy stories from bored data-wallahs creating fanciful scenarios to look busy. 

The Health Foundation hit the headlines but missed the point.

Nothing will make sense until we disaggregate the numbers. Unbundle all this… try to figure out what it means for yer granny.

Not everyone waits for the same diagnostic, or with the same condition, neither in the same part of the country… yes, geography plays a big part, as does the weather. Averages are meaningless. 

Some will have a diagnostic and discover they’re ok… no further action… 70% are likely to be surprisingly quick... and the rest... dunno.

If these numbers are to be of any use we should use them to figure out what’s creating the real enemy of quality and queue theory and that is... variability.

Variability; our old friend Edwards Deming

… uncontrolled variation is the enemy of quality… [the] use of analytics allows us to control … variation…

Queue theory; six points:

  • the arrival process… boundless numbers, some predictability but an infinite combination of conditions and multi-morbidity... variable.
  • service capacity… mostly outstripped by demand... variable.
  • people available to ‘serve’… insufficient and reducing. Predictable.
  • size of the 'customer' population, very variable but weighting possible. Few effective policies to reduce causes of demand
  • queuing discipline… first-in, first-out? No. Variable clinical priority takes precedent meaning many could be ‘parked’ and later, present unexpectedly as urgent
  • Departure process… clogged by poor discharge arrangements... variable

The most useful thing this report says is; 

What matters to individual patients is the time spent waiting.

Correct… so, who will be smart enough to write a report that can tell us about what matters?

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