Manx Care Waiting Times Reports

Total No. Patients Waiting by Referral to Treatment (RTT) Pathway Stage

Median waiting time (Weeks)

*The Gastroenterology daycase waiting list is currently subject to ongoing clinical validation.

Supporting Notes:

• The waiting time information provided will be updated each month as a snapshot of the waiting list position on the day that the report is created
  
  
• Referral to Treatment (RTT) Rules will not be applicable to the waiting lists until such time as the required systems and methodologies are implement within the organisation (see Current Limitations)
  
  
• The Median waiting time for first outpatient appointment is the currently expected waiting time for your first appointment with a clinician within a consultant led service having been referred by your GP/GDP. This may be face to face, online or by telephone
  
  
• The Median waiting time for treatment is the currently expected waiting time for Treatment which may include a procedure or treatment in a daycase or inpatient setting. The waiting time for this stage of the pathway will therefore be in addition to any time waited for a first or follow up outpatient appointment., and/or diagnostic test(s)
  
  
• Some patients may only require to be seen in an outpatient setting to deliver their care, and may not require any daycase or inpatient (Admitted) treatment
  
  
• Some patients may be referred into a given specialty for an outpatient appointment, but receive their definitive treatment under a different specialty or sub-specialty, so some specialties may show as having patients waiting for Daycase/Inpatient treatment but without a corresponding outpatient waiting list
  
  
• Some patients will wait less time than the Median wait time, and some patients will wait longer than the Median waiting time
  
  
• Patients are being managed based on clinical urgency and therefore waiting times can vary depending on each patient's clinical condition
  
  
• Waiting list numbers and average wait times will be subject to change as the waiting list validation processes are a continual cycle as patients progress through the stages of their pathway.

Median Waiting Time

The Median has been included in this reporting as it is represents the wait time experienced by the patient in the middle of the waiting list, whereas a Mean, or 'average' waiting time can be skewed by a small number of patients with either very short or very long  wait times.

• The Mean is the number you get by dividing the sum of a set of values by the number of values in the set
  
  
• In contrast, the Median is the middle number in a set of values when those values are arranged from smallest to largest

Here’s an example set of seven values: 2, 3, 3, 4, 6, 8, 9.

• To find the Mean: add up all the values (2+3+3+4+6+8+9=35) and then divide that total by the number of values (7), resulting in a mean of 5. This is what most people are referring to when they refer to the average of some set of numbers
  
  
• To find the Median: find the value that’s sequentially in the middle. In a set of seven numbers arranged in increasing value, the median is the fourth number (since there are three before and three after). In this set (2, 3, 3, 4, 6, 8, 9), the median is 4. When a set has an even number of values, the median is the mean of the two middle values (in other words, you find the median by adding the two middle numbers together and dividing by two)

It has been one of Manx Care's key objectives under its Operating Plan and Restoration & Recovery (R&R) programme to begin the publication of current waiting list sizes and indicative waiting times by specialty on a monthly basis. This report is the first step in realising that ambition. It is Manx Care's aspiration to have timely access to elective services for its service users and patients. This requires the organisation to have sustainable waiting list sizes across all Consultant led pathways to facilitate maximum Referral to Treatment (RTT) waiting times of 52 weeks for elective care (except where patients choose to wait longer or in specific specialities).

The development of the Waiting Time Information report is therefore an iterative process which will be undertaken over the coming months. The Performance & Business Intelligence (PBI) team remain responsive to feedback received from colleagues, the Board and the public with regard to the evolution of the content and format of this report.

Referral to Treatment (RTT) Pathways

It is one of Manx Care's key objectives to introduce Referral to Treatment (RTT) methodologies to the management of its elective waiting lists.

Under RTT rules, if you are referred for a physical or mental health condition to start non-urgent consultant-led treatment, or be seen by a specialist for suspected cancer, you should be seen at each stage of your pathway within maximum waiting times.

Your waiting time starts from when the hospital or service receives your referral letter.

During this time period, you may:

• Have tests, scans or other procedures to help ensure that your treatment is appropriate for your condition
• Have medicine or therapy to manage your symptoms until you start treatment
• Be referred to another consultant or department

Your waiting time ends if a clinician decides no treatment is necessary, if you decide you do not want to be treated, or when your treatment begins.

This could include:

• Being admitted to hospital for an operation or treatment
• Starting treatment that does not require you to stay in hospital, such as taking medicine
• Beginning fitting for a medical device, such as leg braces
• Agreeing to have your condition monitored for a time to see whether you need further treatment
• Receiving advice from hospital staff about how to manage your condition

The diagram below sets out the key elements of an RTT pathway:

An RTT clock starts when a referral is made to a cosultant-led service with the intention that the patient will be assessed and, if appropriate, treated before responsibility is tranferred back to the referring health professional or general practicioner.

A patient should only be added to the waiting list if they are fit and able to have their treatment.

Clock stops for treatment happen when a first definitive treatment starts, or the patient is added to a transplant list. 

Clock stops for non-treatment happen when:

• it is clinically appropriate to return the patient to primary care
• a clinical decision is made to start a period of active monitoring
• a patient declines tratment having been offered it
• a clinical decision is made not to treat
• the DNA rules apply

Further detail regarding what constitutes a Clock Start and Clock Stop under RTT will be published in Manx Care's 'RTT Rules Suite'.

Until such time as the Referral to Treatment (RTT) functionality and methodologies are embedded within the organisation, the waiting list reporting will be limited to reporting on individual pathway stage, rather than the full pathway from referral to definitive treatment. The pathway stages that can be reported on based on the existing system are:

• Referral to First Outpatient Appointment
• Decision to Treat to Definitive Treatment

Therefore, there may be a period of waiting time between a patient's First Outpatient Attendance and Decision to Treat (where diagnostics and follow up outpatient appointments occur) that cannot be accurately monitored until the RTT system and methodologies are fully implemented. Until the full functionality is in place, a cohort of the activity relating to the diagnostic phase of the pathway will be included within the reported position for the Decision to Treat to Definitive Treatment stage of the pathway instead.

In addition, it will not be possible to apply the RTT Rules Suite to the waiting list data until the RTT functionality and methodologies are fully implemented. Therefore there may be instances where a patient is currently on the waiting list (and included in the figures of this report), but under the RTT rules they would actually have had a valid waiting time clock stop and have been removed from the list.

Planning for the full implementation of RTT is being progressed by Manx Care's Visioning working group. Current estimates place the timescales for implementation at 24 months from the commencement date due to the system configuration required and the training & education programme that will be rolled out to staff.

The long term intention is to implement the following performance standard for RTT pathways:

• 92% of patients on an incomplete pathway (i.e. still waiting for treatment) to be waiting no more than 18 weeks

The tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard is there to take account of the following situations that might lead to a longer waiting time:

• Patients who choose to wait longer for personal or social reasons
  
  
• Patients for whom it is clinically appropriate to wait longer (this does not include clinically complex patients who can and should start treatment within 18
  
  
• Patients who fail to attend appointments they have agreed

It is Manx Care's initial aim to eliminate waits of over 52 weeks for elective care (except where patients choose to wait longer or in specific specialities).

However, given the limitations in managing and reporting waiting times across the full Referral to Treatment (RTT) pathway until such time as the required RTT systems and methodologies are fully implemented, this standard will need to need to be monitored by the individual stages of the RTT pathway:

• Eliminate waits of over 17 weeks from referral to first outpatient appointment for consultant led services (except where patients choose to wait longer or in specific specialities)
  
  
• Eliminate waits of over 17 weeks from a decision to treat to definitive treatment for daycase and inpatient elective care (except where patients choose to wait longer or in specific specialities)

These standards therefore assume a wait time of 18 weeks between First Outpatient appointment and Decision to Treat (see 'Current Limitations' above).

The achievement of these ambitious standards will be entirely reliant on a combination of demand management, the transformation & development of pathways and services, increased efficiency & productivity and additional capacity being identified and available through Phase 3 of the Restoration & Recovery programme, with the latter requiring additional funding to enable the required reductions in waiting list size and wait time to be achieved.

Enhanced Waiting List Management Programme

A programme of work has been established to support the Restoration & Recovery work stream to improve the waiting list position. Central to this has been the implementation of procedural and operational improvements in order to embed the Patient Access Policy (for Elective Care) and improve waiting list management. This includes:

• Waiting List Validation; started in October 2022
  
  
• Patient Tracking List (PTL) meetings (non Cancer); Pilot of PTL process for Orthopaedics commenced in November '22. PTLs have now also commenced for both Ophthalmology and General Surgery
  
  
• Referral & Booking (initial focus on partial booking and patient initiated follow ups)
  
  
• Reduction of patient Did Not Attend (DNA) rates
  
  
• Referral To Treatment (RTT) Rules and System implementation
  
  
• Harm Review

Waiting List Validation

To be able to successfully implement RTT, Manx Care has to validate every new and active referral for each specialty, i.e. outpatient, inpatient and day case, including Mental Health to ensure that the reported waiting list sizes and waits are as accurate as possible.

It is important to note that waiting list validation is to review the quality and quantity of referrals, and is not an endeavour to reduce waiting list numbers. This validation will ensure that patients are on the correct waiting or clinic list.

No patient is removed from a waiting list without a clinical decision.

The validation process is made up of three stage - Technical, Administrative and Clinical:

• Technical validation checks for duplication, referrals that are recorded incorrectly etc

• Administrative validation involves writing to patients and checking that they wish to remain on the waiting list, or not, for reasons such as they have been

• Clinical validation is carried out throughout the validation journey and no patient is removed from the waiting list until a clinician has checked it is appropriate for that patient

Manx Care's Performance & Business Intelligence team have established a dedicated Waiting List Validation team and the required governance and standard operating procedures for waiting list validation and will continue to manage and support this process going forward.