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<\/a>To add to this, Covid has also prompted a greater focus on prioritisation and clinical urgency in allocating care, as opposed to a first come, first served system, which poses added challenges in correctly allocating services when some patients have been on a waiting list for more than two years.<\/p>\n
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How targets fuel a new hierarchy of care: emergencies, long-waiters, then everyone else<\/h3>\n
Despite the impressive efforts and successes of restoring elective activity after the pandemic, as well as the rise of innovative ways to provide care and promote collaboration among providers, we are still far from having room to breathe. In this context of significant mismatch between demand and capacity, the limitations of national targets that would encourage efficient management in a balanced system are laid bare.<\/p>\n
A pertinent example of this is elective waiting lists, which have been the object of various targets to reduce long waits. The good intentions behind these targets are undeniable; no one should be made to wait for care for more than a year. In a system where demand is matched with capacity, such long waits should never be an issue. In principle, a sudden surge in capacity directed at these long waiters might be enough \u2013 at least for some trusts \u2013 to clear them. However, this is problematic for two key reasons: it fails to account for clinical urgency and the resources that must be reserved for the sickest patients, and it directs disproportionate energy to 2 per cent of the waiting list.<\/p>\n
Previous experience shows that initiatives to address targets are incredibly energy-consuming for trusts. They may also fail to gain buy-in when they don\u2019t match local clinical priorities. What we have seen at large trusts is that the backlog of elective diagnostics does not stand a chance in front of the volume of emergency and two-week-wait cancer referrals. As patients approach waiting targets, however, they are pushed to the front of the queue to avoid missing them. This is not solving the backlog issue \u2013 it merely adds another pressure point.<\/p>\n Perhaps more throughput-focused national targets, such as setting a maximum number of waiting-list per head of population, would be more effective while allowing trusts to decide how to manage their own waiting lists.<\/p>\n If there is one thing that the pandemic has demonstrated about the NHS, it is that when empowered, trusts and local systems are pioneers of innovation and can rise to unprecedented challenges. From the London Ambulance Service, which partnered with the London Fire Brigade to deal with rising ambulance demand, to the Royal Surrey NHS Foundation Trust that partnered with a local private hospital to provide excellent palliative care despite the pandemic (NHS Providers<\/a>, 2020), the pandemic bore witness to numerous examples of unparalleled collaboration and innovation.<\/p>\n There is an inevitability about some targets in that they reflect national priorities and are a way of tracking progress and holding systems to account. There is some evidence to suggest they motivate change and can be a catalyst for improvement. But the flipside is that blanket targets don\u2019t take into account local need and they penalise providers that are otherwise making huge progress on elective recovery. They\u2019re also not particularly good at motivating staff in a positive way\u2014health and care professionals understand that targets are organisationally important, but they\u2019re not always aligned with what professionals and patients think is important. If ICBs are to be held accountable for delivering on targets, it only seems fair that they should have a say in what the targets might be and it can be expected that priorities might change from one locality to another.<\/p>\n This should not be seen as a limitation, but as an opportunity. We think ICBs are the key for a more nuanced approach to designing and setting priorities that might catch two (or more!) birds with one stone: managing the elective backlog and addressing local need with highly relevant targets.<\/p>\n ICBs could set their own targets, that are in line with national priorities but refined to fit local circumstances. Local systems could engage their workforce and patient voices in agreeing what these look like. This approach still creates accountability and sets a direction for change (the point of targets) but also gets buy-in from the teams charged with meeting the targets\u2014targets that reflect their priorities and what they see in their own practice.<\/p>\n It doesn\u2019t have to mean a free-for-all or ducking difficult problems. National bodies can still ensure local systems are ambitious, hold them to account, and provide support and guidance to deliver change. Programmes such as GIRFT do this very successfully. Instead, what we propose would allow local systems to have more freedom to invest in novel care strategies to tackle their unique challenges. Importantly, it could be a mechanism to engage with, value and retain the workforce.<\/p>\n Of course, the counter is that differences will emerge across localities. But the truth is that this is the current reality, demonstrated by the charts above. And those differences would likely start to narrow if \u2013 and this is critical \u2013 ICBs are given time to flourish, work to meet local priorities and learn from one another.<\/p>\n About the authors<\/strong><\/p>\n George Bachelor is Co-Founder and Director of Edge Health specialising in the delivery of advisory services and data products that improve operational performance for clients in the health sector.<\/span><\/p>\n Lucia De Santis is a qualified medical doctor and Analyst at Edge Health, providing subject-matter expertise on the clinical\/data interface and coordinating Edge Health’s thought leadership. <\/span><\/p>\n<\/a>
\nICBs create an opportunity to focus on local priorities<\/h3>\n
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