Delivering 18 week pathways for patients Developing Good Practice Pathways

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Delivering 18 week pathways for patients
Developing Good Practice Pathways

• Jenny Bareham
• Head of Service Transformation
• Dr Steve Laitner
• Clinical Advisor -18 Week Pathways (GP Public
  Health Consultant)

November 2006 Version 1.0
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Development of Good Practice Pathways

• Development of 3 symptom based (where possible)
  good practice pathways for the highest volume 12
  specialties
• To
• Challenge existing practice
• Utilise service improvement tools and techniques
• Maximise opportunities for transformational
  change
• Deliver 18 weeks
• To commence publication January 07

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Pathway Development

• To aid delivery against timescales the content of
  the pathways have been split into 2 phases
• Outlining the service model
• Completing the remainder of the template,
  including greater detail incorporating Health
  Care Needs Assessment, Public Health
  Interventions, Activity Data, Quality of Life
  Assessment and Outcome Audit, greater information
  on Workforce.

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Publication of Pathways

• 10 to be published on the Internet end January 07
  
• Refreshed with further information end March 07
  following feedback

Remainder of pathways to be published on the
Internet end February, and refreshed end April.
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First 10 Pathways

• High volume procedures
• The Joint PMDU/DH review (p26) identifies that if
  orthopaedics, gastroenterology, ophthalmology,
  gynaecology and ENT completed their RTT within 18
  weeks, and performance in other specialties was
  as is now, overall inpatient performance would
  rise from c.35 to c.80. Clearly this requires
  delivery for all pathways in the specialties,
  however it supports the focus on these specialty
  areas.
• Difficulty with delivery in 18 weeks (e.g.
  Orthopaedics)
• Potential to alter pathway to shift activity
  away from secondary care (e.g. vasectomy)
• Evidence of limited clinical effectiveness in
  some cases (upper GI endoscopy for dyspepsia,
  surgery for uncomplicated varicose veins,
  hysterectomy for menorrhagia)
• Cover a wide variety of specialty areas

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Benefits

• Create increased opportunities to test the
  pathways and proposed models of care through
  testing and feedback from sites e.g. early
  achievers, Pioneers, and CITECs, including
  additional information required, practical
  arrangements arising from local discussion,
  feedback on the pathways and template
• Create additional time for broader clinical input
  and engagement
• Allow time for further refinement of service
  models
• Avoid overloading the NHS with too many pathways
  to discuss locally at one time

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Principles

• Clinically driven pathways that commence at the
  patients presentation of symptoms and end at
  completion of the patients journey i.e. should
  not end on the point of first definitive
  treatment and clock stops for 18 weeks.
• Pathways must not be defined by whether they are
  delivered in primary or secondary care. Elements
  of the patients pathway must be defined by the
  individual they are required to see and the
  equipment required NOT whether it is primary or
  secondary care provided.
• Be patient focussed e.g. reflect the patients
  view of when the pathway starts and finishes
• Identify areas of clock stop and clock start
  within scope of the principles and definitions
• Draw on the learning from a range of
  pilots/working groups covering 18 weeks issues
• Maximise opportunities for utilising service
  improvement to improve efficiency and
  productivity along the patient pathway
• Identify resource implications for adopting the
  pathway, including workforce and IT

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Developing Good Practice - Networks
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18 Week Patient Pathway Template Tier 1
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Summary Points from Pathways (1)

• Impressive clinical engagement and enthusiasm
• Encouraging clinicians to focus on thresholds for
  clinical assessment, diagnostics, interventions
  and referral
• DRE and PSA for LUTS
• X-ray for knee pain
• Endoscopy for dyspepsia
• Tonsillectomy for recurrent sore throat

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Summary Points from Pathways (2)

• Importance of self care and self assessment
  (supported and unsupported) to manage demand at
  beginning of pathway
• Importance of robust primary care assessment -
  red flags, diagnostic tests, diagnosis, remote
  specialist advice/ referral when necessary

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Summary Points from Pathways (3)

• Highlight the mechanisms to manage demand for
  interventions of limited clinical effectiveness
  such as varicose vein surgery, tonsillectomy
• Importance of patient/ carer information to guide
  informed decision making

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Summary Points from Pathways (4)

• Clearly demonstrating the number of Tiers
  required for each pathway suggesting radical
  changes in
• Direct access to diagnostics from primary care
  (e.g. Back MRI, helicobacter testing)
• Direct listing for surgery from tier 1 - e.g
  cataract from optometry assessment, vasectomy
  from primary care assessment,
• Direct listing for surgery from 1st specialist
  assessment including CATS/ interface
  service)
  

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Summary Points from Pathways (5)

• Driving efficiency
• day case operating,
• numbers of cases per list,
• all day operating lists e.g. Cataract,
• pre-operative assessment

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Final Summary Points from Pathways

• Assessment Alternatives
• Support for self assessment
• Support for self care
• Primary care providers e.g. Optometry
• Diagnostic alternatives
• Helicobacter testing instead of endoscopy
• MRI instead of arthroscopy
• Treatment alternatives
• Primary Prevention (Public Health Interventions)
• Mirena coil for menorrhagia,
• Physiotherapy, weight loss, joint injections for
  knee pain
• Medication for LUTS

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Sign off

• Process for gaining sign off within organisations
  (end January publication
• CAG 24th Sign off
• Feedback from Stakeholders
• Consensus events (March and April)
• Revised pathways before final publication
• ½ day per specialty (clinicians, managers,
  patient representatives)
• 1 day for wider engagement (Map of
  Medicine,e-care pathways, Institute, Improvement
  Foundation etc)

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Spread and Adoption

• Existing events and meetings
• Telling the pathway story
• FAQs section
• Feedback area for responses/queries/input
• Development of spread and adoption plan building
  on good practice nationally and internationally