Lesley Burn

1

Delivering the 18 weekpathwayPhysiological
measurement

• Lesley Burn
• Dr Kerry Tinkler

2
Main Policy Drivers

• NHS Improvement Plan (2004)
• - 18 week wait by 2008 capacity
  bottlenecks
• - System improvement more productivity
• - Health as well as Health Services
  Public Health
• - Long Term Conditions shifting
  boundaries
• - Plurality of provision
• - Patient Choice a change of culture
• Commissioning a patient led NHS (2005)
• - move from provider driven to
  commissioning driven
• - new organisations and structures
• - needs based and front line driven
  (access and choice)
• - improved commissioning arrangements
  (practice based )
• Our health, our care, our say (2006)
• - focus on prevention and health promotion
• - more care outside of hospital and in home
• - encouraging innovation and competition
• - joined up approach

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The challenge of 18 weeks
Implementation Plan direct access to diagnostic
services not included but still needs to be
included in work programmes for sustainable long
term provision
18 Weeks
GP
IP
OP
D
OP
GP Visit
1st OutpatientAppointment
Decision to treat
Treatment
The time from the first outpatient to decision to
treat includes the most significant challenges
including all diagnostics and subsequent
outpatients
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Diagnostic clearance times
Data published in early July 2006. 5 PM tests in
top 6
Diagnostic test clearance times
Most significant challenge to reducing diagnostic
waits to below 13 weeks
Demand expected to rise before Dec 2008
Source Pilot site data
Total sample size 100,000 waiters Unvalidated
data, from pilot study of 13 self selected trusts
therefore may not be representative".
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What are Physiological
Measurement Services

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• Disciplines included
• - Audiology
• - Cardiology ( non invasive and invasive)
• - Gastrointestinal physiology
• - Neurophysiology
• - Ophthalmic and Vision Science
• Respiratory and Sleep physiology
• - Urodynamics
• Vascular technology
• Tests undertaken
• 300 different tests and procedures, accounting
  for approx 10 million pa
• Therapeutic intervention closely related to
  diagnostic test in some disciplines

PATHOLOGY
IMAGING ENDOSCOPY
PHYSIOLOGICAL MEASUREMENT

• Policy initiatives include
• Diagnostics/18 wk
• LTC neurology
• MHAS/PPA
• Screening programmes
• CHD NSF
• Care Settings
• Mainly secondary care based
• -Access often controlled

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Physiological Measurement services may be
distributed across organisations

• Discipline
• Audiology
• Cardiac physiology
• Gastrointestinal physiology
• Neurophysiology
• Ophthalmic and Vision Science
• Respiratory and sleep physiology
• Urodynamics
• Vascular technology

• Service department/organisation
• Stand alone/ENT
• Cardiology
• GI Med or surgery/Endoscopy
• Clinical neurophysiology/neurology
• Ophthalmology/Vision Science unit
• Respiratory Medicine/Sleep unit
• Urology/Medical Physics
• Vascular surgery/Imaging

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The work of Physiological Measurement departments
cross many patient pathways
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DIAGNOSTIC TEST COMPONENTS
PATIENT ASSESSMENT (pre-testing) EQUIPMENT D
IAGNOSTIC TEST (Simple, Routine, Specialist,
Complex) RESULTS INTERPRETATION
REPORTING CLINICAL ADVICE MANAGEMENT

• Contra-indications to test investigation being
  performed
• Identification of pre-test requirements
• Appropriateness of referral related to
  presenting symptoms
• Clinical status assessment immediately prior to
  test/investigation Preparation (can include
  environments)
• Calibration/verification and QA
• Maintenance/repair
• Operating safety ( impact on environments)
• Protocols/standards
• Patient specific modifications
• Technical acceptability
• QA of test performance/procedure
• Technical acceptability (limitations)
• Selection of result
• Linked to presenting symptoms/provisional
  diagnosis
• Pattern Recognition (sophistication?)
• Comparison with internal QA within sets of
  results
• Support Differential Diagnosis

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Complete PM diagnostic process undertaken by
range of healthcare professionals whose
contribution needs to be identified
.and others, eg. helpers
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Physiological Measurement National
Programme

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Physiological Measurement Issues

• Underinvestment and lack of specific
  commissioning arrangements (block contracts/no
  separate tariffs) - Physiological Measurement not
  a priority
• Unknown Demand/increasing prevalence of
  conditions and more guidelines
• Repertoire of tests changing (new technology,
  more complex tests)
• PM diagnostics within patient pathways referral
  criteria, activity linked to specialities,
  patient outcomes, demand and requirements of
  local health economy
• Inefficient processes - waiting list management,
  backroom functions, old ways of working (? Actual
  capacity)
• Workforce - ? affordable, no matching to service
  needs or diagnostic test components
• Leadership learning from others, sharing,
  challenging, representation
• Long term sustainability

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Physiological Measurement National Programme
Overarching workstreams
Supporting commissioners to provide streamlined
and efficient services for patients
Linking equipment to IT systems generation of
information to shape services
New models of care, including in primary care
with measures of impact
Physiological Measurement Framework to be
published in 2007 What is PM doc soon
A physiological measurement leadership strategy
and development of networks
Workforce toolkit of issues, priorities,
protocols and solutions
Pathway mapping to develop protocols based on
clinical governance and standards
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4 Priority National Projects -all due to report
early in 2007others covering remaining 4 areas
may follow

• Audiology linked to National Audiology Action
  Plan
• Cardiology
• Peripheral neurophysiology
• Respiratory and Sleep related breathing disorder
  measurements
• Will focus on capacity and demand, good
  practice and service models including workforce,
  commissioning guidance and implementation
  strategies

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Physiological Measurement Development sites
Physiological Measurement Strategy Group
Medics, scientists and other members of the MDT
commissioners, SHA, PCT,
Physiological Measurement Leadership Group and
workshops
Physiological Measurement Framework
Development ideas..
Cardiology
Ophthalmology
GI Physiology
Neurophysiology
Respiratory physiology
Audiology
Royal Free
Leeds
Vascular technology
Urodynamics
University Hospital Birmingham
North Staffordshire
Royal Devon and Exeter
Pennine Acute
East Kent
Referral
Norfolk and Norwich
Service delivery
Workforce
Commissioning
March 2006
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Identifying Development Sites

• Geographical spread
• Diversity of Trusts and environment
• Test all 8 areas of physiological measurement
• Internal team integrated within management and
  clinical structures
• Connections across the health economy

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Engaging with diagnostic servicesdevelopment
process

• Pathway mapping
• Capacity and demand analysis
• Analysing workforce functions

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Engaging with diagnostic servicestesting
solutions

• Improving service delivery
• Improving referrals across the whole pathway
• Workforce role redesign
• Working with commissioners

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Norfolk Norwich University Hospitals NHS Trust
Audiology

• Training audiologists to remove ear wax.
• July 2006 One month audit of patients with
  troublesome wax
• attending the departments.
• 1366 patients were seen where wax could affect
  procedures.
• 11 (156) of those had wax.
• At least 100 could have had ear wax removed by an
  audiologist.
• Gain of 11 appointments per week.

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University Hospital of North Staffordshire NHS
Trust GI Physiology

• Process mapping to understand how the service is
  delivered.
• Active waiting list management.
• Waiting lists have reduced between February and
  August 2006.

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University Hospital Birmingham NHS Foundation
Trust Cardiology

• Bundle tests and schedule them before the first
  outpatient appointment so that test results are
  available at consultant appointment.
• Reduction in the number of days patients wait for
  an opinion at consultant review.
•  

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Leeds Teaching Hospitals NHS Trust Urodynamics

• Creation of a dedicated centralised urodynamics
  department within the integration of 2
  gynaecology departments.
• Service capacity has been increased to 10
  sessions a week.
• No waiting list for urodynamics diagnostics
  capacity currently exceeds demand.
•  

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Royal Devon Exeter NHS Foundation Trust
Ophthalmology

• A level 3 technician role to provide support to
  the glaucoma clinic.
• Technician undertakes disc photography and other
  investigations in the unit.
• Releasing capacity especially in the glaucoma
  pathway so ophthalmic practitioners can see
  more patients.

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Leeds Teaching Hospitals NHS Trust Cardiology

• Community screening for ECG and 24 hour BP
  monitoring.
• Current pathway

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Leeds Teaching Hospitals NHS Trust Cardiology

• New pathway

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Technology
Patient
Process
Workforce