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The role of PBC in the 18-week wait

Dr David Jenner explains what you need to know and do about the ‘last Mohican’ of central targets

Dr David Jenner explains what you need to know and do about the ‘last Mohican' of central targets.

What exactly is the 18-week wait target?

The 18-week wait target was really the end trajectory of the NHS plan published in 2000 at a time when waits for elective surgery were often 18 months or more. It sets a target for a maximum 18-week wait from the point of referral to definitive treatment for all outpatient referrals. At the time it seemed almost incredible in its aspirations but with massive NHS funding increases that have doubled the budget it really does now seem likely to be achieved in most areas by the end of next year.

When does it have to be achieved by?

The commitment is to deliver this target by the end of December 2008. But for this financial year there is a target of 95% of outpatient pathways and 85% of pathways requiring an inpatient episode to be delivered within 18 weeks by the end of March 2008, (see box at bottom of page for more on patient pathways)

Just how important is this target?

It is an absolute top-line priority. The NHS Operating Framework, which is the business plan for the NHS, lists only four top priorities this year:

1 financial balance

2 18-week wait

3 reducing hospital-acquired infections

4 reducing health inequalities.

Will consortia and practices have to meet these figures?

Yes without doubt, and any PBC proposal this year should explain how it will help achieve the 18-week wait target. Despite national spin about no more targets, the 18-week wait is a must-do for this Government but when it is achieved I do not think waiting times will be lowered further.

But my PBC budget is based on historical activity – won't I need to commit more money to bring down waiting times?

Yes and yes – but PCTs have been given on average 8% more money this year and special allowances from SHAs to help deliver the 18-week wait target. Ask them for some of this. It is clearly logical they should share this with you but according to PBC rules they are not obliged too.

How well is the NHS doing so far?

Data published in May suggests 40% of inpatient admissions are being delivered on time but Department of Health statistics for June show only about half of patients come in under the 18-week threshold. The department claims it's ‘on track' to meet the outpatient target but it's going to be tough.

But I thought there were to be no more central targets?

That is the mantra – but this is the ‘last Mohican' of central targets. After this has been achieved it's likely there will be no more central targets.

Exactly which referrals are covered by the target?

All referrals from GPs and other clinicians with PCT-approved referral rights to hospital consultant-led services, GPSI services and consultant-led community services. Note that this includes consultant mental health services, consultant-led dental services, and audiology and pain services which were previously exempt from waiting time targets.

Which referrals are excluded?

Referrals to non-consultant mental health services (psychology and counselling, for example) and community therapy services (such as physiotherapy).

What about diagnostic services?

This is more complicated – but where the expectation is that direct access diagnostics will obviate the need for a qualifying referral as above, the target does not apply. If, however, the diagnostic service is a prelude to further referral, for example ultrasound for likely clinical diagnosis of biliary colic prior to probable referral for cholecystectomy, the clock starts ticking from the time of the referral for the scan.

And referrals to community assessment services?

These are not excluded from the target unless the perceived end point at the time of referral is that no qualifying onward referral will take place. Otherwise the clock starts ticking from the time of referral to the CAS as in the diagnostic scenario above. It is therefore vital that CAS services do not add delays to clinical pathways.

When exactly does the clock start?

From when a service receives the letter of referral from a GP or a patient converts their unique booking reference number(UBRN) when using Choose and Book. For inter-consultant referrals the clock starts at the time the referral is made (and similarly for emergency to non-elective hospital referrals) – for example, torn cartilage presenting at A&E and referred on for elective arthroscopy. If a referral is made in error to the wrong department the clock stops until a correct referral is made.

Are there any exemptions?

Yes, if a patient delays the referral to treatment pathway at any stage the target is void and the trust involved can claim exemption. There is also going to be a ‘tolerance' built in to the target for genuine difficulties in establishing a diagnosis, but there will not be an exception code for this. In practice this means 100% achievement may actually be 98% achievement. Details on the tolerance have yet to be announced and a cynic would say it will be announced at a level that ensures the target appears to have been met!

How will all this be monitored?

Good question. Connecting for Health is supposed to be producing a referral tracking tool. However, as only 40% of referrals nationally are being made through Choose and Book and the software is late I am not sure this will be ready on time and work.

What is the best thing I can do under PBC to help achieve the target?

Quite simply eliminate any unnecessary referrals. This avoids putting any more patients in the system and also saves money to invest elsewhere to help buy extra services to meet the 18-week wait. Simple peer review of referrals within practices or some sort of referral triage can usually reduce referrals by 10%. Look carefully, though, with your PCT at inter-consultant referrals – as consultants know more and more about less and less these are rising at five times the rate of GP referrals. You can stipulate new to follow-up ratios with financial penalties if exceeded in your contracts with provider trusts.

What are the likely pressure points for the 18-week wait?

Nationally these are audiology (hearing aid referrals), endoscopy, echocardiography and orthopaedic referrals. All but the latter can be easily met by community-led services provided by GPSIs, private companies or even freelance consultants, potentially beating the tariff price. Ask your PCT now for its quarter one and quarter two performance against 18-week wait targets and spot the areas at issue. Ask them how you can help them achieve this through PBC – they may well be prepared to invest resources here.

Is this good for patients or simply more rationing?

It is good for patients. Most patients and GPs complain about long waits for secondary care. I believe the patient pathways can really help improve the referral process to avoid delay or duplication but they do need some sensitivity to deal with an individual patient's fears and concerns. If they were literally applied by a manager in a pre-approval referral centre they would be a disaster. For example, a patient with great fear of cancer will demand a referral no matter how hard their GP tries to convince them their symptoms make cancer unlikely. And don't we all remember a time when the patient's fears were correct?

But doesn't this mean I won't make any savings under PBC this year?

No, but it makes it less likely, especially if the PCT does not share some of its extra funds with you to achieve that. Remember, though, this is an elective activity target and 50% of your PBC budget goes on emergency admissions and A&E attendances. There is plenty of opportunity for savings there as well as prescribing savings. Realistically, plan to spend more on elective activity in 2007/8 until and unless you can reduce referrals into the system. If you do this, savings will begin to appear (but at least three months later).

Tell me in a nutshell one single thing I should do now

Ensure your PCT is sharing with you benchmarked referral data and performance against the 18-week wait target. Peer review referrals to check they are all necessary and look to see how through PBC provision you might be able to provide extra services to reduce the 18-week wait. Ask your PCT how you can help – if they don't answer sensibly ask the local SHA.

Dr David Jenner is NHS Alliance lead for PBC and a GP in Cullompton, Devon


Any PBC proposal this year should explain how it will help achieve the 18-week wait q1 Look carefully at inter-consultant referrals – these are rising at five times the rate of gp referrals q2 What are patient pathways? What are patient pathways?

Go to and look under ‘commissioning pathways'. There are no fewer than 35 individual pathways covering common conditions for referral, co-written by clinicians from the royal colleges. These are excellent templates to promote effective referral and not just limit or ration referrals. A lot of energy and expertise has gone into designing these and they are an excellent template to refine locally. However, hardly anyone knows of them. Find them and discuss with colleagues in primary and secondary care, then adapt them locally.

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