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Editor's blog Monday 2 November 2009: Legally enforceable waiting times and the DH's consultancy spend

Good afternoon.

Last Friday's Times had this story that the Cabinet has agreed to press forward legislation guaranteeing that patients exceeding NHS waiting time targets will be treated privately, to be included in the next Queen's Speech.

The article suggests that patients who are in danger of breaching maximum times (18 weeks for elective care, and two for cancer) would have to be informed of their legal and enforceable right to choose another provider - including independent providers.

The timing is interesting, as the debate at the recent NHS Alliance conference and an NHS Confederation policy seminar crystallised the sense that the PbR tariff risks contributing to the bankruptcy of the NHS if we continue as we are. HSJ recently reported an anonymous briefing that a split tariff will be on its way.

A proxy problem
In seeking to make this right to treatment within a timeline legally enforceable, three factors are at work.

The first is party political. Gordon Brown is determined to create clear water between Labour and the Conservatives. The Conservatives plan to abolish all targets: it is interesting to consider whether they come out and say they would repeal such legislation if passed.

The second is restrictive. The old school solution to a financial crisis was to cancel elective operations towards the end of a financial year - 'demand postponement'. This option would no longer be available under such a law, although the rapid raising of referral thresholds using such tools a referral management centres would probably become some localities' tactic. More to the point, it would be counter to the business plan - indeed, the legal duty - of the many NHS foundation trusts to fail to maximise their incomes in such a way.

The third is theatrical. This is not currently very much of a problem. Data given to the Times journalists suggests that currently, in the English NHS, about 37,000 patients are at risk of breaching 18 weeks, and the DH considers that about half that number - 18,500 - are being "let down by the system".

It is somewhat surprising to see this presented as a suggestion about hospitals, when it is in fact a commissioning thing. 18,500 elective operations risking breaching 18 weeks strongly implies that this is an Aunt Sally of an issue. Much bolder would be to do something about people waiting for access to psychological therapies.

The high cost of management consultants
The FOI towel has been thrown in by the DFH's recent announcement that NHS organisations' spending on management consultancy will have to be itemised and published from next financial year.

However, the doyen of eschewing the taking of prisoners that is Nick Timmins revealed in the FT that the DH's own spending on management consultancy has exceeded £580 million over the past four years.

Even as the more manageable-sounding £145 million it averages out to a year including the money spent (or in some cases, wasted) on nationally-mandated turnaround teams in 2006-7, these are sizable sums.

The DH's latest capability review by the Cabinet Office, published in July, found that leadership was a medium-rating "development area" in three of the four categories; two of the three categories in strategy; and one in delivery. This did represent significant improvement on the frankly lousy findings in 2007, but is not necessarily going to inspire the greatest faith that the DH is a very savvy consumer of management consultancy.

Management consultancy is not necessarily a bad thing per se. There are good and bad examples. However, a strong sense emerges from off-the-record conversations that the use of management consultants has become an automatic choice - an item of faith.

What would be genuinely worth knowing, and add very real value to the conversation, would be whether there had been any attempt to evaluate whether this spending of £580 million of our tax money had produced any lasting positive results.

After all, it's all about outcomes. Isn't it?