Reducing elective waits: Delivering 18 week pathways for patients

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Reducing elective waitsDelivering 18 week
pathways for patients

• 18 Weeks National Implementation Director
• Philippa Robinson

May 2007 Version 1.4
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• 2008

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Why the 18 Week challenge is different

• 12.5 million patients are referred each year for
  elective hospital care
• This compares to 500,000 patients referred each
  year with a suspected cancer

• Scale nationally the number of patients
  involved is huge

• Patients currently wait less than 13 weeks to be
  seen for the first time in out-patients, the
  majority less than 13 weeks for any single
  diagnostic test and less than 26 weeks on a
  waiting list if in-patient or days case admission
  is needed
• Need to move thinking from stage of treatment to
  referral to treatment (RTT)

• Waiting times have never been lower

• When you join up each stage of a patients
  journey only 35 of patients who are admitted
  from waiting lists are currently treated in 18
  weeks or less from referral to treatment the
  waits for patients treated as out-patients are
  shorter with 70 to 80 treated within 18 weeks
• Reducing waits for diagnostic tests is essential

• But there is much more to do

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Why the 18 Week challenge is different

• Improving the access of primary care teams to
  diagnostic and therapy services will reduce the
  number of patients who need to be seen in
  out-patient clinics, and will speed up the
  diagnosis of patients who do need referral to a
  consultant
• New community-based models of care

4. We will need to care for more patients outside
of hospital

• We can work smarter by cutting out unnecessary
  steps and creating new pathways for patients to
  follow
• e.g. one-stop services using new and existing
  technologies to speed up access and
  communications

5. We cant end waiting by doing more of the
same
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Why the 18 Week challenge is different

• Money will follow the patient through payment by
  results
• We can increase capacity by using a wider range
  of providers
• Patients can choose where they are referred for
  treatment
• Practices can influence how resources are used
  through practice-based commissioning

6. NHS reforms will help

• the reductions in waiting times have to be
  delivered alongside financial balance

7. Finance
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Latest programme news Engagement
Communications

• Clinical
• Stakeholder Group and Clinical Advisory Group 10
  Ministerial Regional meetings scheduled with
  clinical networks (7 held)
• Guidance for PwSIs (26 April)
• Stakeholder
• My blog
• Conferences HSJ Theatre Utilisation 17 May
  RSM 6 June UK Radiological Congress 12 June
  NHS Confederation 20-22 June)
• End waiting, change lives campaign to support
  local delivery of 18 weeks - packs sent to LHCs.
• Clinicians focus group
• Communication toolkits - 50k funding to SHAs
• Sponsorship HSJ awards
• Patient and Public
• Patient and Public Champion Neil Betteridge, CE
  Arthritis Care.
• Patient experience metrics
• Quality of life measures
• Patient leaflets
• Patient held record

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Latest programme news Policy System reform
Performance Management

• Policy System Reform
• Commissioning Framework for Health and Well-being
  (Mar 07)
• Practitioners with special interest April 2007
• Free Choice for all elective care April 2008
• Orthopaedics July 2007
• Other specialties TBC
• Guidance end May
• Must be able to meet 18 week milestone and target
• Directly bookable
• Necessary CNST in place
• Info for referrers
• Support for patients

• Performance Management
• March 08 milestones
• 85 for admitted patients 90 for non-admitted
  patients
• RTT trumps stages of treatment
• Patient tracking list (PTL) pilots.
• Pilots felt that a PTL for all patients is
  required to deliver the target.
• Pilots found that a PTL for patients requiring
  admission easier to generate
• Non-admitted PTL requires clinic outcomes to be
  recorded

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Latest programme news Measurement Navigation

• Measurement
• Baseline Exercise summer 2006
• - 35 admitted patient pathways less than 18
  weeks 70-80 non admitted patient pathways
  less than 18 week
• RTT data for admitted pathways to be published
  June. RTT non-admitted pathways end Sept.
• This is the methodology to be used to submit RTT,
  not baseline methodology
• No delays achiever
• Diagnostic data collection March 07 data
• Patients waiting under 13 weeks for 85 tests
• Audiology accounts for ¾ of all over 18 weeks
  waits
• Excluding audiology patients waits under 13 weeks
  for 95 tests

• Navigation
• Work with CfH on sustainability of Patient
  Administration Systems (PAS) for 18 weeks data
  measurement
• Close working with 7 leading existing PAS
  suppliers
• Implementing CB to be standard method of
  referral and entry into 18 week pathways
• Modifying SUS (Secondary Uses Service) to help
  track patients prospectively

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Latest programme news - Specialty and Diagnostics
National programmes

• Specialty and Diagnostics National programmes
• What is Physiological Measurement (published 4
  May)
• Good Practice guides to be published for
  neurophysiology, respiratory/sleep and cardiac
  physiology (May - June 07)
• Orthopaedics SHA road shows on commissioning and
  delivering orthopaedics services summer 07

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Latest programme news Service Transformation
Intensive Support

• Service Transformation
• 33 18-weeks Commissioning Pathways on website. 6
  out of 7 consensus events held. Pathways being
  amended following events. Commencing phase 2 -
  implementation
• 13 Early Achievers aim to deliver 90 admitted
  and 95 non-admitted by December 2007
• Therapies self referral pilots. Report March
  08
• Therapies scoping exercise. July 07
• Clinical Assessment Centres central consultants
  specialists committee GP committee - set out
  key guiding principles of RMC scheme.
• Gold standard GP to consultant referral
• Prime purpose of referral management to improve
  patient pathway
• Only introduce after full local discussion
• Should not cut across patient choice principles
• Intensive Support
• Team now working with all SHAs and many local
  PCTS and Trusts
• Concentrating on improving measurement and data
  capture processes
• Piloting developments of PTLs and Inter Provider
  transfers

Service Transformation and Commissioning Service
Transformation and Commissioning Service
Transformation and Commissioning
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The Practice based Commissioning (PbC) challenge

• to improve services for patients
• to increase clinical engagement in commissioning
  decisions
• to achieve the best outcomes with the investment
  made
• demand management
• by aligning financial responsibility with the
  clinical decision- making

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Practice Based Commissioning (PbC) and 18 weeks

• 18 week target can drive PbC
• PbC Consortia need to be up to speed on 18 weeks
• utilisation of 18 week care pathways-good tool to
  engage primary and secondary care clinicians
• HOWEVER turn this from a top down to a locally
  owned process

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Practice Based Commissioning (PbC) and 18 weeks

• under PBC, GP practices have far greater freedom
  to ensure that services are tailored to the
  specific needs of their patients
• PBC should therefore lead to local innovation
  resulting in flexible high quality service

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PCT engagement and recruitment

• Phase One National
• One PCT site per SHA - 28 sites
• Phase Two Waves 2 and 3
• Spread to over 70 of PCTs by the 10 Improvement
  Foundation centres- details www.improvementfoundat
  ion.org
• Local Improvement Team

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What services are being tackled?

• Scheduled Care
• Dermatology
• Rheumatology
• Musculoskeletal
• Gynaecology
• ENT
• Diabetes
• Minor Surgery
• Urology
• Cardiology
• Diagnostics

• Unscheduled Care
• Case Management/Care Co-ordination
• Minor Injuries
• COPD/Pulmonary Rehab
• Heart Failure

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Examples of service changes

• Diabetes Primary Care Service reduced wait
  times
• TO Triage of referrals
• COPD peer to peer patient education re self
  management
• ENT Improving skill mix GPsWI Specialist
  Nurses in primary care
• GP education advice from secondary care
  colleagues reducing referrals
• Pulmonary Rehab Primary Care Management
  access to leisure facilities
• GP liaison at acute trust to co-ordinate
  emergency admissions
• Peer to peer review of referrals
• Elderly care admission avoidance

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Priority areas for getting to 18 Weeks

• Engage and communicate with everyone involved in
  delivering 18 Weeks locally
• With patients
• Between Commissioners and Providers
• Between Clinicians and Managers
• Between Departments
• Between Purchasers and suppliers
• Plan to deliver March 08 milestones
• Establish LHC-wide governance arrangements
• Plan capacity needed across the LHC
• Develop trajectories and track performance
  against them

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Priority areas for getting to 18 Weeks

• Measuring pathways and tracking patients
• Trusts submitting data to DH each month
• Transform services to deliver 18 Weeks
• Shifting from small service-focused improvement
  to whole pathway transformation across
  organisational boundaries
• Ensure clinical leadership throughout the process
• Continue work with Pioneers to develop solutions
  to 18 weeks measurement and implementation
• Involve all stakeholders in the process
• Challenge current practice and drive change

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Benefits of 18 weeks

• For patients
• Reduced anxiety through quicker diagnosis
• Reduced pain from quicker relief of symptoms
• Less disruption to normal life through prompt
  attention and convenient appointment
• Greater confidence in NHS no hidden waits
• Better experience during referral to treatment
• For public
• Greater confidence in NHS the right treatment
  is available without unnecessary delay
• Fair return on increased spending on the NHS
• Greater equality of experience for all patients

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Benefits of 18 weeks

• For clinicians, GPs and other staff
• Opportunity for hospital clinicians and GPs to
  work together
• Opportunity to shift services to Primary Care eg.
  minor surgery, access to diagnostics
• Release of personal time and resources for other
  purposes (including development of primary care
  services)
• Consultants only see patients who require
  specialist skills
• Fewer patient complaints and improved working
  life from dealing with more satisfied patients

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More information - 18 weeks

• www.18weeks.nhs.uk
• Service Transformation homepage
• Patient pathways
• National Projects homepages
• Latest news
• Official publications
• Best practice guidance and case studies
• Tools and Techniques
• NHS Institute Productivity Metrics -
  www.productivity.nhs.uk
• International Forum on Quality and Safety in
  Healthcare, Barcelona - http//barcelona.bmj.com
• NHS Modernisation Agency 10 High Impact
  Changes for Service Improvement and Delivery
• Directory of resources for Workforce Planning-
  www.healthcareworkforce.org.uk
• Improvement Foundation - www.improvementfoundation
  .org

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Additional support - PbC

• PbC tools, guidance resources on website
• web forum
• support for local learning exchanges
• internet based training web cast presentations
• simulation events
• commissioning course
• Practice Manager Events
• PCT PBC days
• provider events
• consortia training
• secondary care conferences
• non-exec training