In February 2020, just before the pandemic, we had 4.5 million people on an NHS waiting list according to British Medical Association analysis. The latest data, from August 2022, showed that this list has grown to 7 million. We know that waitlists are not static, conditions develop as people wait for treatment, and the scale of the challenge to reduce waiting times feels immense. How do we tackle this challenge while ensuring that progress in other areas is not compromised along the way?
As part of our online Q community event on Tuesday 18 October 2022, we wanted to explore the role of improvement in reducing waiting times.
This isn’t just numbers, this is people’s lives.
The first session was hosted by GP and Divisional Medical Director for Central London Community Healthcare NHS Trust, Rammya Mathew who reiterated the scale of the challenge, reminding participants, ‘This isn’t just numbers; this is people’s lives.’
Participants heard from Sir David Dalton, former Chief Executive at Salford Royal NHS Foundation Trust; Ailsa Brotherton, Director of Continuous Improvement at Lancashire Teaching Hospitals NHS Foundation Trust and John Boulton, Director of NHS Wales Quality and Patient Safety and Patient Safety/ Director of Improvement Cymru.
The second session, hosted by Q’s Head of Insight, Evaluation and Research Matthew Hill, looked at how to make progress on equity while reducing waits.
Clifford Mitchell, Regional Senior Improvement Advisor at the Improvement Hub for HSCQI, interviewed Amy Bowen, Director of System Improvement at North London Partners in Health and Care and Professor Kiran Patel, Consultant Cardiologist and Chief Medical Officer at University Hospitals Coventry and Warwickshire NHS Trust.
Looking back to find a way forward
Revisiting the role of improvement to reduce wait times in the early 2000s, there are a lot of successes that we can draw on today.
John Boulton talked about research into the science of waiting and queueing theory. He gave the example of Tesco, which promised in the early 2000s that if there were more than two people waiting in front of a customer, they would open another till.
We need to build that deep expertise to actually understand waiting at a different level.
‘Health care isn’t Tesco, it’s much more complex and the application of things such as queuing theory really does need to be taken off the bookshelf and really bought back to the fore,’ he said. ‘We need to build that deep expertise to actually understand waiting at a different level and it’s much broader than just simple improvement science.’
Evolving to see the whole system
Ailsa Brotherton shared how in Central Lancashire they were taking the learnings from the 2000s and looking at improvement on multiple levels from a micro-level on wards and departments to an Integrated Care System (ICS) level.
‘At an ICS level we have worked with other improvement leads… to make sure that improvement is embedded as part of our big priorities for the ICS,’ she said.
Health care isn’t Tesco, it’s much more complex.
‘The NHS has been familiar for a long time with what it has to do but perhaps rather less on how to achieve it,’ Sir David Dalton said. Evolving from top-down targets and performance management, improvement has progressed to staff empowerment and co-creating with staff and patients. Ensuring the consistent implementation of change and securing improvements are likely to be the next areas of focus.
Putting equity in the picture
While we strive to reduce waits how do we maintain and continue to improve services equitably? This is difficult and demanding work that requires a nuanced approach, however urgent the need may be.
The current focus on inequalities can be a ‘golden thread’ through improvement work, according to my colleague Matthew Hill. He shared some emergent findings from Q’s work using action learning and focusing on data to move past backlogs and help ensure equitable access to services.
To get the same outcome for every patient does not require the same input.
‘There’s a tension between efficiency and equity…The most efficient solution in the short term isn’t usually the most equitable one,’ Amy Bowen said. Good data can help drive the decision-making around these trade-offs. She discussed the power of a population health management approach to holistically identify the needs of the whole patient and put in place proactive interventions. Multidisciplinary teams working across primary and secondary care were able to have a positive impact on people’s experience, access and outcomes.
Professor Kiran Patel was also seeing improved outcomes through improved access. Agile wait lists meant they could meet patients’ needs as their conditions changed. ‘We have to do things both differently and differentially,’ he said, explaining that during the height of the pandemic he received a letter from a patient who couldn’t afford to attend remote appointments because of limited and expensive internet access. ‘To get the same outcome for every patient does not require the same input,’ he concluded.
We know that if we restore services based on waiting times alone it drives inequality. Taking a holistic approach to individuals and a community asset-based approach are important considerations in the balance between efficiency and equity.
Watch the sessions from the online Q community event on YouTube and access additional resources below.