NHS 18-week treatment target incentivises staff to ignore patients waiting longer

The NHS 18-week treatment target incentivises staff to ignore patients who have been waiting longer, a new study suggests.

Under the NHS constitution, 92 per cent of patients must be treated within 18 weeks of a referral from their GP.

But a study of 144 hospital trusts in England between January 2016 and September 2021 showed a large spike in the number of trusts exactly meeting the 92 per cent target threshold followed by a sharp drop after this objective had been achieved.

It suggests that patients were no longer a priority after the target had been hit, although NHS England dismissed the claim as “nonsense”.

The phenomenon has been dubbed the “threshold effect” and academics from the University of Birmingham said it also discouraged hospitals from treating patients as early as possible.

Researchers Professor Richard Lilford and Laura Quinn, of the Institute of Applied Health Research, at Birmingham, told The Telegraph: “The priority is lower once the threshold has been crossed.

“The target provides no encouragement to treat patients who have only been waiting for a short time or who have already passed the 18-week wait.

“We urge governments to do proper prospective evaluations to observe the average effect of targets.

“We have shown that they have a downside. Now the onus is on the Government to examine to see if any benefits justify the harm.”

The 18-week target was introduced in 2012 and covers admission to hospital, surgery, starting a course of drugs, fitting a medical device, agreeing to monitor a condition, or receiving advice on how to manage a condition.

The new analysis looked at waiting times for 13 major treatment groups including cardiology, general surgery, gynaecology, trauma and orthopaedics, and urology.

The figures repeatedly showed that trusts were aiming for the 92 per cent target, rather than trying to get as many people as possible within the 18-week limit. Those who knew they would not hit it had no incentive to even get close, the authors warned.

Writing in the BMJ Quality & Safety, the authors said that the government could consider introducing rewards or fines for multiple threshold levels to keep hospitals striving to improve performance.

In a linked editorial, Nigel Edwards, chief executive of health think tank the Nuffield Trust, said the study highlighted the unintended consequences of setting targets.

He added: “While targets can be effective and are an important part of public accountability (the study) provides more evidence that they can also produce unintended or unanticipated consequences, some of which are unhelpful.

“A rigid focus on hitting the 18-week waiting target for 92 per cent of patients could distort clinical decision making, leading to clinicians being less engaged in the process and also leading to some patients waiting significantly longer once their treatment time exceeds 18 weeks, as their treatment time ceases to influence the reported performance.

“Hospitals doing better than the target may allow their performance to slip back to the target level. Hospitals that have no chance of meeting the target may choose to direct their efforts elsewhere.”

Number of trusts meeting target has worsened

Their analysis also showed that the proportion of NHS hospital trusts meeting the target has worsened over time, falling from 92 per cent in 2015-16 to 64 per cent in the pandemic year of 2021-22.

The proportion of people on the waiting list who have waited more than 18 weeks went from 8.6 per cent in 2015/16, reaching 38.4 per cent during the Covid-19 pandemic in 2020/21 before dropping to 33.8 per cent in 2021/22.

An NHS spokesman said: “The suggestion that the NHS is incentivising trusts not to bother treating people once they pass 18 weeks is nonsense - treatment priority is determined by the clinical needs of patients as identified by clinicians as well as those waiting longest.

“The NHS has a clear plan in place for reducing the Covid backlog, which has inevitably built up as a result of the pandemic, with significant progress reducing the longest waits.”

A Department of Health and Social Care spokesman said: “Cutting waiting lists is one of the Government’s top five priorities and we want patients to have access to treatment as quickly as possible – which is why the 18-week referral to treatment standard is in place.

“We have already made significant progress – 18-month waits have been virtually eliminated and we are taking immediate action to bring down waits of over a year.

“We are also going further to use the independent sector so patients can be treated more quickly – there are currently 116 community diagnostic centres and 93 surgical hubs open, helping to deliver thousands more checks, scans, tests and operations.”