Editor's blog Wednesday 20 April 2011: Kings Fund launches quarterly NHS performance review

The first thing to say about How is the NHS performing? Quarterly monitoring report, the new initiative from the Kings Fund, is that as it admits prominently, it is based on data from a small sample. 26 finance directors gave their answers via an internet survey last month.

Half of the panel were from acute trusts (9 foundation trusts, 1 specialist); about a quarter from mental health trusts (4 foundation trusts); and a fifth from PCTs, with regions’ mix and size represented in the sample. Their views are sought to add a qualitative perspective to the incomplete and unadjusted data that is available in real time.

The second thing is that this is exactly the sort of thing that a leading think-tank should do - and that a Government whose presumption is towards more openness of public data should support. It will be interesting to see how the latter pans out in practice.

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Key findings
Uncertainty - For 2011-12, 24 of the 26-member panel surveyed have productivity targets in excess of 4% (it has been challenging for the NHS to achieve 2% in the decade of big funding growth). Of those 24, 18 are uncertain of meeting their 2011-12 target.

Money and targets - Their top reported priorities were keeping in budget; continuing to meet targets; meeting increased demand and maintaining relationships. behind these followed maintining or improving quality; managing with reduced capacity; and last of all, collecting data.

The Efficiency Fairy cometh (hopefully) - The three top tools for maintaining productivity are seen to be front-line efficiency; workforce; and whole system efficiency. (It is notable, if worrying, that the first and third of these solutions put faith in The Efficiency Fairy showing up and hanging around. Tellingly, one finance director commented, “A saving is not a saving until the activity has reduced AND the beds or theatres have been closed AND the jobs taken out. Only then do both commissioners and providers save money”).

Getting real – or at least, frank - When asked how government could help, most respondents suggested more realism (or perhaps frankness) was needed. The impact of tariff changes, rationing and low potential from back-office savings all cropped up; as did various system rules and priorities.

Good news
There is good news on delayed transfers of care – it showed a fall for March 2011, in line with previous pot-winter peak effects.

Clostridium difficile numbers are likewise going the right way, with a fall in February 2011. Current annual rates of C. difficile are running at around 11,000 cases, down from nearly 20,000 in 2008. MRSA figures also shows a fall.

Workforce, too, continues to rise (though somemight debate for whom this is good news). As the text drily notes, “with little or no real increases in funding for the next four years and the abolition of PCTs and SHAs, the impact on compulsory redundancies will be interesting to track”. It sure will.

Median waiting times for inpatients, outpatients and those still waiting fell in February 2011, in line with an expected seasonal effect.

Less good news
Diagnostic test median waits are beginning to rise. Median waiting times for diagnostics fell in January and have now risen in February 2011, following the typical seasonal trend for these months. The December 2010 peak represented the longest diagnostic waiting time since October 2007.

The latest data for A&E waits (2010/11, quarter 3) showed an increase in the percentage waiting more than 4 hours; this figure tends to be higher in quarter 3 each year; however, the latest peak is higher than those for quarter 3 in 2009/10 and 2008/9. In fact, although the percentage remains relatively small, the last time it was higher than this was in 2004/5.

The latest 18-week referral-to-treatment waiting times data for February 2011 shows increases in the percentage of patients waiting longer than 18 weeks for inpatients and outpatients. The proportion still on waiting lists and waiting longer than 18 weeks fell, as did the proportion waiting longer than 6 weeks for diagnostics. However, for all stages of waiting the trend since June 2010 remains upwards.

The DH response has been that the data used are uncorrected, which report co-author Professor John Appleby freely acknowledged on his appearance on BBC Radio 4 Today this morning.

DH cash commander-in-chief David Flory also defended that change in the waiting time trend in his appearance on the same programme with NHS Confederation acting CE Nigel Edwards.

The waiting time rise is a trend - not yet huge, but it is a trend. Edwards rightly pointed out the false economy of letting waiting times run out to the horizon, in cases where the operation will still need to be done.

The real issue here is around variations in referral thresholds, activity and outcomes. We are engaged in the slow process of making all of this better, with such excellent tools as the NHS Atlas Of Variation and NHS Comparators. It is also about changing working patterns and practices.

These things are do-able, and they are difficult.

We should all welcome a new tool from the Kings Fund to help track the progress that the NHS needs to make, and to draw attention back to where it needs to be - on near-real-time data and who is doing what to whom, where, what the outcome was and how the patient felt - i.e. were they better for the healthcare? (I've also just seen a very good new tool from NHS Local - the NHS Atlas of Risk for patients and staff to assess local health challenges.)