18 WK REFERRAL TO TREATMENT TARGET:

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18 WK REFERRAL TO TREATMENT TARGET A CLINICIANS
PERSPECTIVE Vinod Achan Interventional
Cardiology Fellow St Georges Hospital and
Medical School
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MEDICAL REACTION TO TARGETS
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INITIAL REACTION TO TARGETS

• ?Political interference with the NHS (18 months
  to 18 weeks sound bite)
• ?Management applying pressure on healthcare
  professionals (interferes with patient care)
• Will make life more difficult
• One of several changes in the new NHS (PbR, PBC
  etc etc)

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BUT

• Five out of nine key targets related to waiting
• Penalties for failure to reach targets
• Patients may choose to go elsewhere
• Increasing involvement of the independent sector
• Successful trusts will attract patients from out
  of area

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• Clinicians need to be engaged
• Collaboration
• between clinicians and management
• between trusts and PCTs
• between tertiary and secondary centres
• ESSENTIAL

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WAR ON WAITING
Phase 1 1997-2000
Phase 2 (NHS Plan) 2000-2004

• Reduce max waits for OP appt (6m to 3m) and IP
  admission (18m to 6m)
• Initiatives to increase supply (treatment
  centres, day surgery)

• Reduce no people waiting (100000 fewer pts by end
  of first term) rather than waiting times
• Inappropriate objective

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Phase 3 (gt2005) 18 WEEK REFERRAL TO TREATMENT
TARGET (NHS Improvement Plan 2004)

• By end Dec 2008, noone will wait gt18wk from GP
  referral to hospital treatment
• Primary care referrals to be made through Choose
  and Book
• Currently approx 50 pts receive Rx within 18 wks
  of referral (average wait 30 wks)

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18 WEEK REFERRAL TO TREATMENT TARGET

• Applies to elective work
• Focus on whole patient journey
• Speeding up treatment stages alone may not be
  sufficient
• Many waits overlap
• Optimise patient flow and remove bottlenecks
• Focus on hidden waits (diagnostic)

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Strategies to achieve 18 week target

• Process mapping to identify bottlenecks / hidden
  waits
• Systematic data collection
• Direct GP access to diagnostic facilities
• One stop clinic
• Diagnostic and treatment combined (LHC?PCI)
• Pre clinic diagnostics (may not work with Choose
  and Book)
• CLINICIANS (and patients) MUST BE INVOLVED IN
  REDESIGNING PATIENT PATHWAYS

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Patient Pathways

• Early referral and selection of patients
• Adopt the minimum number of steps (saves PCTs
  money)
• Frequent decision making
• Avoid duplication of tests (DOAS) and unnecessary
  delays
• Continuous patient tracking, regular audit and
  evaluation

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www.18weeks.nhs.uk
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Elective Chest Pain Pathway
Chest Pain
One Stop Diagnostic Clinic
Option 1 ETT, ?echo
GP AE
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Elective Chest Pain Pathway
Chest Pain
One Stop Diagnostic Clinic
Option 1 ETT, ?echo
Option 2 ETT, echo Cardiologist assessment Risk
Stratification
GP AE
Choose and Book OUTSIDE AREA
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Elective Chest Pain Pathway
Chest Pain
One Stop Diagnostic Clinic
GP Local Hospital AE
Option 1 ETT, ?echo NP assessment
Option 2 ETT, echo Cardiologist assessment Risk
Stratification
Choose and Book OUTSIDE AREA
Y
LMS disease or 3VD likely?
Urgent invasive angiogram
N
S
Day case LHC?Proceed
MDT Discussion
PCI
CABG
Successful discharge
Local F/U and rehabilitation
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Clinicians need

• Education
• Excellent frequent communication
• between clinicians and management
• between trusts and commissioners
• between tertiary and secondary centres
• Easy access to reliable, accurate data
• To be notified as soon as the clock starts

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Clinicians need

• Clear definitions eg. When does the clock stop?
• An understanding of how will this relate to
  Choose and Book, PBC, PbR etc etc
• Whole systems thinking (Consultants to have a
  feel for GP referral patterns etc)

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BATH MODEL
Tap
Drain
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BATH MODEL
DEMAND
Referral
Water level Waiting Time
Bath size Capacity
SUPPLY
Treatment
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BATH MODEL
DEMAND
Target
SUPPLY
Reducing waiting times lowering the water level
in the short term By extra lists, extended
working days, extra locum staff
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CATCHING UP IS NOT THE SAME AS KEEPING UP
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DEMAND
DEMAND
SUPPLY
SUPPLY
If Supply gt Demand, bath empties ie. Wasted
capacity, Money runs out
If DemandgtSupply, bath overflows ie. Waiting
times too long LESS CHOICE
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• ?reduced hospital referrals by GPs
• Increasing community care GPSI
• Competition from ITCs and distant trusts

DEMAND
Target

• Adapting to increased acute workloads
• New technologies
• Sharing of pathways by different departments

SUPPLY
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Maintaining the lower water level in the LONG
term will require

• Management of fluctuations in demand and supply
• Flexible working practices to maximise use of
  resources
• Minimal waste of capacity

True choice requires surplus capacity
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Future 18 week patient pathways will
be Clinician led Patient centred and PCT
supported
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