‘Intelligent targets’ new plan for surgery

Jan 21 2008 by Madeleine Brindley, Western Mail

BY THE end of next year, assuming the NHS hits its targets, the era of long waits for hospital-based treatment in Wales will be over.

The Welsh Assembly Government wants no one to wait more than 26 weeks, from the time they are referred by a GP, for their treatment to start, by December 2009.

This is a far cry from the early dark days of devolution, when waiting times soared to as much as four years for many unfortunate orthopaedic patients.

Perhaps tellingly, given both the different historic and current policies of the governments in Westminster and Cardiff Bay, patients in England should already be enjoying shorter waiting times – the English target of an 18-week maximum wait from referral to a hospital consultant to the start of treatment, must be met this year.

But what happens when – and if – Wales meets its 26-week target? Will patients continue to be seen on an ad hoc basis within this time limit, or will the NHS finally start treating patients based on clinical priority?

As the waiting times targets currently stand, after December 2009 everyone can expect to be treated within 26 weeks, except cancer patients, who are already covered by specific one and two-month targets and angiography patients (four months).

But what about people with conditions which have the potential to progress rapidly and cause greater physical and emotional pain?

For example, some forms of bowel disease can deteriorate quickly and yet there is no compulsion for these patients to be seen as early as possible, whereas patients with bowel cancer are fast-tracked through the cancer waiting times target.

The Western Mail understands that the Assembly Government is considering the concept of “intelligent targets”, which would ensure that some patients are seen ahead of others.

Professor Mike Harmer, Wales’ deputy chief medical officer, said, “Targets were originally set to improve health service provision but their broad-based nature means that they are not always appropriate for individual conditions.

“Targets have been used to improve both quality of care and efficiency – in the case of many of the waiting time targets, they should soon be achieved and thought needs to be given as to how we deal with future targets.

“Do we decide to continue to drive down the overall waiting times or do we look at a more disease-sensitive approach?

“Having a universal maximum 26-week waiting time limit is a challenge – but achievable – with specific shorter targets for conditions such as cancer.

“But for non-cancer conditions, we know that there are some, for example varicose veins, which may not get worse if they are treated in 26 or 52 weeks, while, there are other conditions – particularly those that necessitate time off work or incapacity and pain – that should be treated much sooner than 26 weeks to limit the development of chronic incapacity.

“The urgency in some of these cases may be similar to that expected for cancer treatments.

“Such considerations over the urgency of specific treatments may help to provide more appropriate treatment within a reasonable average waiting time.”

Another factor which could determine whether some patients with specific conditions are prioritised over others is the development of new medicines and treatment techniques.

This could mean that some conditions which currently necessitate treatment in hospital will, in future, be treated in the community, bolstering Assembly Government plans to move towards a predominantly community-based health service.

Dr Tony Calland, chair of the BMA’s Welsh Council, said, “One of the criticisms of the basic waiting times targets has been that people who have significant clinical priorities have been seen after those people with waiting time priorities – that’s a mad way to run a health service.

“For example, inflammatory bowel disease can cause death and, before that, severe malnourishment. Patients with this condition are just as important as, if not more, than those with bowel cancer.

“To make the argument to the public is that the sickest people should get treated first.

“The problem has been that the sickest are not necessarily treated first at the moment.

“Someone may be fed up because they can no longer walk down to the 18th hole as easily as they could a few years ago but they will not expect to be seen ahead of someone with suspected bone cancer or other serious orthopaedic condition.”

But in order to prioritise the most clinically needy patients, and ensure that the overall 26-week waiting time target is maintained, the NHS in Wales will need a radical overhaul.

The current configuration of the system, which relies heavily on hospital-based treatment, is at the mercy of emergency demand.

Elective surgery – waiting times work – has traditionally ground to a halt during the winter months because there are simply not enough beds in which to put these patients, as a result of an influx of emergency patients requiring treatment.

This ongoing problem has been confounded, in recent years, by consistently high levels of bed blocking, particularly in South Wales hospitals.

Treating some hospital patients in the community – as per the Assembly Government’s Designed for Life plan for the NHS – is one means of creating additional capacity to ensure a quick flow of patients through hospital, as is expanding day case capacity.

Another option which must seriously be considered is separating elective from emergency.

The now abandoned reconfiguration proposals for West Wales had ventured some way down that route, envisaging a largely elective role for Prince Philip Hospital, in Llanelli – the removal of emergency surgery would suggest that this idea is being recognised in part – and for Neath Port Talbot Hospital.

Prof Harmer added, “In addition to more disease-specific targets and new developments, we may need to consider separating elective from emergency activity within hospitals, as one of the problems the health service has always had is that the two are dealt with within the same bed allocation.

“Winter pressures, for example, restrict surgical activity and targets are difficult to meet under these circumstances.

“If we were able to separate the two services, targets should be more easily achievable. To undertake such a separation would be a challenge as it would be important to ensure that the emergency care is still adequately provided while elective care is effectively protected.”