Katy Harris

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Reducing Elective Waitswhat the 18 Week target
really meansBANES PCT event, 19 September 2007

• Katy Harris
• Policy Implementation Lead, 18 Weeks

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Content

• This presentation outlines
• Context of the 18 week target
• Overview of definitions
• The current position
• 18 week pathways

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Context of the 18 week target

• 18 weeks - a commissioner target
• 18 weeks from GP referral to first treatment
• Applies to all patients referred to consultant
  led services
• Measuring referral to treatment time RTT

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18 week target
Target is live from beginning March 2008
85 for admitted 90 non admitted patients

• Target is live from beginning March 2008
• 85 of admitted patients treated in 18 weeks
• 90 of non-admitted patients treated in 18 weeks

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Therefore from 27th October 2007, all patients
will be on an 18 week pathway
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Context of the 18 week target

• Principles of the 18 week target
• Timeliness as a quality measure for the benefit
  of patients
• Pathway focus and service redesign requires GP
  and consultant leadership
• Not just a waiting list initiative wide
  ranging, NHS wide
• Financial balance and 18 weeks are not mutually
  exclusive

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Context of the 18 week target

• Key challenges for the NHS
• Transformational change culture change
• Pathway measurement as opposed to numbers
• waiting
• Capture clock stops and clock starts
• Capture data electronically and link events
  this will support pathway management
• Transfer data smoothly and efficiently between
• providers

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Clock starts and stops
Where does the clock stop?
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Clock Rules Starting the Clock (1)

• What starts the clock?
• Any referral from primary care to
• Consultant led service (irrespective of setting)
• Cancer services
• Obstetrics
• Diagnostics that are straight to test
• Referral management centres (RMCs) and Integrated
  care, assessment and treatment services (ICATS)
• Practitioners with special interests if they are
  part of a referral-management arrangement as
  defined

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Clock Rules Starting the Clock (2)

• What does not start the clock?
• Referrals to
• Non consultant led services eg. therapy,
  healthcare science or mental health services
• Diagnostics that are not straight to test
• Primary dental services provided by dental
  students in hospital settings

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Clock Rules Starting the Clock (3)

• What is the date of the clock start?
• For Choose Book the date when the patient
  converts their UBRN
• The date when the provider receives notice of
  referral
• If patient is referred to wrong specialty needs
  to be re-referred, the clock still starts on the
  date that the original referral letter was
  received or UBRN converted.

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Clock Rules Stopping the Clock (1)

• What stops the clock?
• First definitive treatment begins
• Decision not to treat
• Decision to embark on a period of watchful
  waiting or active monitoring
• Decision to add a patient to a transplant list
• Decision to return the patient to primary care
  for non consultant led treatment in primary care
• Decision to return the patient to an RMC for non
  consultant led treatment

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Clock Rules Stopping the Clock (2)

• What does not stop the clock?
• Administration of pain relief before a procedure
• Steps to manage condition before definitive
  treatment begins
• Consultant-to-consultant referrals where the
  underlying condition remains unchanged
• Making a tertiary referral or a referral from one
  provider to another

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Where are we now?Latest RTT performance - June
07

• 54 of admitted patient pathways under 18 weeks
  (June 07)
• 70 for data completeness (June 07)

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Current position - specialties
Around two thirds of long waits are in 5
treatment function areas (TO, Gen Surgery,
Ophthalmology, Gynaecology, ENT)
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RTT Admitted patients Orthopaedics and all
specialties
of patients treated 18 weeks
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The Orthopaedics challenge
of patients treated in timeband
Clock stop timeband
Chart showing RTT data for orthopaedic patients
by time band.
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MRI Waits by time bands
Number of MRIs per month
Length of time waited
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Peripheral Neurophysiology
Number of PN tests per month
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Audiology Assessments BY SHA FOR MAY 2007
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Key points Planning
Essential to have a detailed, WRITTEN plan, with
named leads, actions, timescales, numbers and
deliverables
Best plans cover whole local health community,
are owned by Trust and PCTs, with Executive
leadership
Best plans are concise and focus on priorities
80/20 rule
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Key points Data capture

• Providers must be able to identify all clock
  starts and must record all clock stops regardless
  of where care is delivered

Use of a minimum data set when a patient is
transferred between providers will be mandatory
from Jan 2008

• Referrals to all medical and surgical consultant
  led services start clocks includes RMCs
  providing a triage function

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Key points Measurement

Robust data is essential to plan service
provision and to help deliver appropriate, timely
care
Pathway measurement and identification of key
events is essential for providers to manage the
pathway using a patient tracking list or PTL
Comprehensive performance reports are essential
for all stakeholders acute trust and PCT
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Key points Engagement
Everyone has a role to contribute in the delivery
of 18 weeks
The patient perspective is central important
not to meet the target but miss the point
Clinicians involved at national level RCGP sits
on 18 Week Stakeholder Board primary care
representation on 18 Week Clinical Advisory Group
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Key points Managing waits
Apply known good practice wherever there are
waits validate, reduce carve out, tackle
variation.
PCTs should apply same discipline for managing
RMCs / provider function as an acute trust
applies to outpatient department
Revisit demand, capacity and variation in
services where RTT is longest
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Patient perception

• Historically patients may anticipate a long wait
• Need to ensure that patients are ready, willing
  and able to be treated before referral
• The GP has a role in helping to inform the
  patient which in turn improves the patient
  experience

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Intensive Support

• Intensive Support Team now working with all SHAs
  and many local PCTS and Trusts
• Have focused on improving measurement and data
  capture processes now moving to improving
  pathways
• Working on inter-provider transfers

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Practice based commissioning

• Under Practice Based Commissioning, GPs have far
  greater freedom to ensure that services are
  tailored to the specific needs of their patients
  and to innovate locally
• New models of commissioning will be needed to
  meet and sustain 18 weeks
• Use leverage of 18 weeks to focus discussions
  around local service requirements and put in
  place transformed pathways across local systems
• Clear thresholds will need to be in place to
  stream patients effectively to the right
  clinician in the most appropriate setting

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18 week care pathways

• The 18 week team have led the development of 35
  condition and symptom based (where possible) good
  practice commissioning pathways for the highest
  volume 12 specialties
• To
• Challenge existing practice
• Utilise service improvement tools and techniques
• Maximise opportunities for transformational
  change
• Support commissioners to deliver 18 weeks

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Principles

• Clinically driven
• Pathways must not be defined by whether they are
  delivered in primary or secondary care, or by
  which specialty or professional.
• Patient focussed
• Identify areas of clock stop and clock start
• Draw on the learning from a range of
  pilots/working groups
• 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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Process for Development (1)
Agreed condition and symptom based pathways to
work on following feedback from clinical leads
Reviewed existing research on each
pathway (existing pathways, systematic reviews,
clinical guidelines)
Developed and agreed generic 18 week pathway
template for populating
Identified Project Leads for each
specialty Leading the development of the pathways
working with identified clinical leads, and
projects/workstreams Established working group of
project leads and additional support posts to
prevent overlap etc
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Process for Development (2)
Identified clinical leads and launch of Clinical
Advisory Group Royal Colleges invited to submit
clinical leads through Stakeholder Board Further
clinicians identified through existing groups
CAG membership and terms of reference agreed.
Development of pathways Drafts of populated
pathways Diagnostics developed through existing
routes to feed into pathways Examples of good
practice included from Imaging, Physiological
Measurement, Pioneers, CITEC sites etc
Consensus Events Local events to share and come
to consensus on content Amended where appropriate
according to feedback
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Pathway Development 2 phases

• Outlining the service model to support
  commissioners in commencing local discussions on
  service models - transforming the pathway
• Populating the remainder of the template,
  incorporating information to support
  implementation applying service improvement
• Technology enablers
• Workforce skills and competencies
• Service improvement models
• Quality of life assessments
• HRGs and OPCS codes
• Identifying commissioning levers
• Incidence and prevalence

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Phase 2 - Examples (not all information is
necessarily applicable to this pathway)
Streamlining services to improve productivity
Introducing extended roles - skills and
competency based
Assessing QoL from the outset
Running a one-stop clinic
Direct access diagnostics unbundling tariff
Day Surgery
Using PACs to ease reporting
Using alternative providers for review and
follow-up
Direct listing for surgery
Early pre-assessment
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Commissioning Pathways

• Chest pain (angina)
• Breathlessness (heart failure)
• Palpitations (atrial fibrillation)
• Recurrent sore throat
• Reduced hearing - adult (sensorineural hearing
  loss)
• Reduced hearing - child (glue ear)
• Lump in groin/navel (inguinal/umbilical hernia)
• Upper abdominal pain /- Jaundice (gall stones)
• Varicose veins
• Persistent/atypical headache
• Transient Ischaemic Attack (or sudden
  neuroligical loss)
• Blackouts
• Tremor (Parkinson's disease)
• Dizziness
• Dental pain
• Mouth lesion
• Skin lesion
• Reconstruction of breast

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Commissioning Pathways

• Indigestion (dyspepsia)
• Rectal bleeding
• Change in bowel habit
• Heavy menstrual bleeding (menorrhagia)
• Pelvic Organ Prolapse (POP)
• Female sterilisation (laproscopic sterilisation)
• Female Incontinence
• Gradual sight loss (cataract)
• Chalazion (cyst)
• Back pain
•  Hip pain (OA hip)
•  Knee pain (OA knee)
•  Pins/needles/numbness in fingers (carpal tunnel
  syndrome) 
•  Shoulder pain
• Blood in Urine (Dip-stick Haematuria/ Microscopic
  Haematuria) 
• Difficulty passing urine (Lower Urinary Tract
  Symptoms (LUTS))
• Male contraception (vasectomy)

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18 week care pathways example

• Charing Cross Hospital, Hammersmith Hospitals
  NHS Trust one stop cardiac care service ensures
  the patient has access to a clinician, diagnostic
  investigations and treatment all on the same day.
  The aim is to promptly identify, diagnose and
  risk stratify new presentations of suspected
  cardiac disease and, where a positive diagnosis
  is made, immediately initiate effective
  management. 87 of patients reported a positive
  experience at the new clinic.

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18 week care pathways - example

• University Hospital of Hartlepool, North Tees
  and Hartlepool NHS Trust Nurse-led follow-up of
  mastectomy service. The patient pathway has been
  redesigned so that the average length of stay is
  now reduced from 4 days to 23 hours, and maximum
  use is made of specialist nursing skills in both
  hospital and community settings. The risk of
  hospital acquired infection is thus greatly
  reduced and patients are mobile more quickly,
  thereby reducing the risk of deep vein thrombosis
  and post-operative complications.

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18 week care pathways

• Oldham ICATS - GPwSI or Nurse Consultant sees,
  screens and works up patients who need to see a
  consultant. Only those with serious pathology
  need to see a consultant, and those who do not
  are rapidly assessed, treated and discharged back
  to their GPs. Those who do need to see the
  consultant are fully investigated, so decision on
  treatment is made at first consultant
  appointment. 75 of referrals are managed
  without the need to see a consultant. Patients
  are assessed within 2-4 weeks, with a further 2-3
  weeks for follow-up. RTT clock stops by 11
  weeks.

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18 week care pathways

• Other LHCs are currently developing 18 week
  pathways
• Aim to provide consistent and high quality care
  best use of resources
• Need to be clinically led across primary and
  secondary care
• Implemented as part of an 18 week LHC action plan
• Linked to service redesign

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Thank you some useful resources

• 18 weeks resources, including commissioning
  pathways
• www.18weeks.nhs.uk
• Clock stop/start queries data18weeks_at_dh.gsi.gov.u
  k
• Practice Based Commissioning Improvement
  Foundation
• www.improvementfoundation.org
• Primary Care Contracting
• www.primarycarecontracting.nhs.uk
• NHS Institute for Improvement and Innovation -
  tools and techniques relevant programmes
  include No Delays, Quality and Value, Care
  Outside Hospital
• www.institute.nhs.uk