Waiting list behaviour and the consequences for NHS targets

The United Kingdom’s National Health Service (NHS) is investing considerable resources in reducing patient waiting times for elective treatment. This paper describes the development of a waiting list model and its use in a simulation to assess management options. Simulation usually assumes that waiting is adequately described by simple queuing disciplines, typically first-in-first-out. However, waiting in the United Kingdom’s National Health Service is a more complex phenomenon. The waiting list behaviour is explored through an analysis of the changes in waiting time distributions for elective orthopaedics in one Scottish Health Board, NHS Fife. The evolving distributions suggest that there have been substantial changes in priorities in response to the various NHS targets. However, in the short or medium term, the form of the distribution appears reasonably stable, providing a basis for estimating future waiting times in different scenarios. A model of the waiting behaviour and prioritisation in the appointment allocations was embedded in a simulation of the complete elective orthopaedic patient journey from referral, through outpatients and diagnostics to surgery. The model has been used to explore the consequences of various management options in the context of the NHS target that no patient should wait more than 18 weeks between referral and treatment

Simulation analysis of the consequences of shifting the balance of health care: a system dynamics approach

Objectives: The shift in the balance of health care, bringing services 'closer to home', is a well-established trend. This study sought to provide insight into the consequences of this trend, in particular the stimulation of demand, by exploring the underlying feedback structure. Methods: We constructed a simulation model using the system dynamics method, which is specifically designed for the analysis of feedback structure. The model was calibrated to two cases of the shift in cardiac catheterization services in the UK. Data sources included archival data, observations and interviews with senior health care professionals. Key model outputs were the basic trends displayed by waiting lists, average waiting times, cumulative patient referrals, cumulative patient activity and cumulative overall costs. Results: Demand was stimulated in both cases via several different mechanisms. We revealed the roles for clinical guidelines and capacity changes, and the typical responses to imbalances between supply and demand. Our analysis also demonstrated the potential benefits of changing the goals that drive activity by seeking a waiting list goal rather than a waiting time goal. Conclusions: Appreciating the wider consequences of shifting the balance of care is essential if services are to be improved overall. The underlying feedback mechanisms of both intended and unintended effects need to be understood. Using a systemic approach, more effective policies may be designed through coordinated programmes rather than isolated initiatives, which may have only a limited impact

The NHS performance framework: taking account of economic behaviour

The provision of quantitative information has been given a key role in securing good performance in the new NHS. A new National Performance Framework has been proposed encompassing a number of dimensions of performance. Whilst this approach to managing the NHS is welcomed, it is essential to understand the strengths and limitations intrinsic to the use of performance indicators for this purpose. In particular, complex behavioural consequences may arise in response to the collection and dissemination of performance data, some of which may be unintended, potentially dysfunctional and damaging for the NHS. Results from a recent study on the performance of NHS Trusts are used to illustrate the sort of unintended side-effects which occur within the current system and which may in principle be replicated in the new system in future. Whilst the possibility of such consequences does not invalidate the potential of the new Performance Framework to secure the desired changes in the NHS, it does suggest that careful attention needs to be paid to the assessment of unanticipated side-effects.performance, NHS Trusts

Use of Targets to Improve Health System Performance: English NHS Experience and Implications for New Zealand

The setting of quantitative, time-limited ?targets? backed up by institutional and managerial rewards and sanctions has been a notable feature of performance improvement efforts in the National Health Service (NHS) in England since 1998 and especially in the period 2000-2004. Performance improved in the areas covered by English NHS targets, most markedly in relation to waiting times, but also in relation to treatment outcomes. None of the other parts of the United Kingdom followed England and similar trends were not observed, particularly not in waiting times, despite similar injections of funds. Despite the improvements in performance in target areas, targets were criticised, principally, for having perverse and unintended consequences (e.g. distorting priorities, encouraging ?gaming?, etc) which could have potentially out-weighed their benefits. On the other hand most experts in performance improvement in public services argue that carefully chosen, incentivised targets are a useful part of the performance management repertoire when used well (e.g. when sanctions and rewards are proportionate). Some dysfunctional consequences are to be expected, but can be mitigated. Given the similarities between the English NHS and the New Zealand public health system, there is scope to use targets and related incentives sparingly to improve performance in New Zealand in areas of high importance to government and the public.performance measurement; performance management; performance improvement methods; target-setting; control of public services

Modelling the feedback effects of reconfiguring health services

The shift in the balance of health care, bringing services ‘closer to home’, is a well-established trend, which has been motivated by the desire to improve the provision of services. However, these efforts may be undermined by the improvements in access stimulating demand. Existing analyses of this trend have been limited to isolated parts of the system with calls to control demand with stricter clinical guidelines or to meet demand with capacity increases. By failing to appreciate the underlying feedback mechanisms, these interventions may only have a limited effect. We demonstrate the contribution offered by system dynamics modelling by presenting a study of two cases of the shift in cardiac catheterization services in the UK. We hypothesize the effects of the shifts in services and produce model output that is not inconsistent with real world data. Our model encompasses several mechanisms by which demand is stimulated. We use the model to clarify the roles for stricter clinical guidelines and capacity increases, and to demonstrate the potential benefits of changing the goals that drive activity

Incentives and Targets in Hospital Care: Evidence from a Natural Experiment

Performance targets are commonly used in the public sector, despite their well known problems when organisations have multiple objectives and performance is difficult to measure. It is possible that such targets may work where there is considerable consensus that performance needs to be improved. We investigate this possibility by examining the response of the English National Health Service (NHS) to waiting time targets. Long waiting times have been a key issue for the NHS for many years. Using a natural policy experiment exploiting differences between countries of the UK, supplemented with a panel of data on English hospitals, we examine whether high profile targets to reduce waiting times met their goals of reducing waiting times without diverting activity from other less well monitored aspects of health care. Using this robust design, we find that targets led to a fall in waiting times without apparent reductions in other aspects of patient care.health care, waiting times, targets, incentives

A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service

Objective: To evaluate CBTp delivered by non-expert therapists, using CBT relevant measures. Methods: Participants (N=74) were randomised into immediate therapy or waiting list control groups. The therapy group was offered six months of therapy and followed up three months later. The waiting list group received therapy after waiting nine months (becoming the delayed therapy group). Results: Depression improved in the combined therapy group at both the end of therapy and follow-up. Other significant effects were found in only one of the two therapy groups (positive symptoms; cognitive flexibility; uncontrollability of thoughts) or one of the two timepoints (end of therapy: PANSS general symptoms, anxiety, suicidal ideation, social functioning, resistance to voices; follow-up: power beliefs about voices, negative symptoms). There was no difference in costs between the groups. Conclusions: The only robust improvement was in depression. Nevertheless, there were further encouraging but modest improvements in both emotional and cognitive variables, in addition to psychotic symptoms

The NHS plan: an economic perspective

The NHS Plan, published in July 2000, presented an ambitious blueprint for the transformation of the way the NHS delivers health care. The backdrop to the Plan is the substantial increase in resources for the NHS promised for the next 5 years. At the heart of the Plan is the aim of ensuring these resources are used effectively to provide a health service “designed around the patient”. After reviewing the perceived flaws in the current system and dismissing the notion of alternative systems of health care funding, the main part of the Plan outlines the strategy for tackling the shortcomings. The discussion is wide-ranging and includes not only those areas we would expect to see covered, such as the interface between health and social care and the performance management system, but also issues such as investment in infrastructure, the relationships between the NHS and the private sector and key personnel issues such as the supply of health care professionals and their contractual arrangements. This discussion paper summarises the main elements of the Plan before focusing more closely on seven key themes on which economic analysis has a distinctive insight to offer – investment, information, labour markets, the independent sector, waiting times, performance management, and patient and carer responses. Some of the preconditions for success of the Plan are outlined and gaps in the available evidence to support various aspects of the Plan are highlighted. Our conclusions suggest that there is reason to be optimistic that the Plan will deliver many of its lofty aspirations if two key conditions are met. First, that front-line staff are on board and have the resources and the will to help implement the Plan; and second, that political expediency and the desire to achieve short-term goals does not drive out the commitment to the long-term aims for the NHS.The NHS Plan

An economic framework for analysing the social determinants of health and health inequalities

Reducing health inequalities is an important part of health policy in most countries. This paper discusses from an economic perspective how government policy can influence health inequalities, particularly focusing on the outcome of performance targets in England, and the role of sectors of the economy outside the health service – the ‘social determinants’ of health - in delivering these targets.