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the biggest thing since Körner
Brian DerryASSIST Vice Chair
Director of Informatics The Leeds Teaching Hospitals NHS Trust
brian.derry@leedsth.nhs.uk
Tactical and strategic informatics challenges of 18 weeks – an acute
Trust perspective…
or…
Outline
1. Where are we now?
2. Where do we need to get to?
3. Informatics issues
4. Conclusions
Where are we now?
…I really wouldn’t start from here…
Current access targets
Now Mar 07 Mar 08
• Outpatients 13w 11w 5w
• Inpatients 26w 20w 11w
• “Diagnostics” 26w 13w 6w
• Cancer 14/31/62 days
Stocks at month end only – except Cancer
STOP PRESS
LDPs 18 weeks for
Admitted patients 85% tolerance
Non-admitted patients 90% tolerance
By March 2008!!!!!!!
Breaches - IP & OP
0
20
40
60
80
100
120
140
160
180
200
Ma
y E
nd
Jun
En
d
Jul E
nd
Au
g E
nd
Se
p E
nd
Oct
En
d
No
v E
nd
De
c E
nd
Jan
En
d
Fe
b E
nd
Ma
r E
nd
Ap
r E
nd
Changed to 6/13 targets
IP
OP
Waiting times target coverage
GP ref OP att consDecisionTo admit
Admit & treat Home
Other ref 1st att2nd+ atts
Admit & cancel
OP att nurse
DecisionTo admit
Any primary care
2nd+ atts
X
X
XX
X X
LTHT Outpatient Attendances 2005/6
GP-Cons 1st13%
GP-Cons 2nd+26%
Other-Con 2nd+41%
Other-Cons 1st8%
Other-NonCons 1st1%
Other-NonCons 2nd+6%GP-NonCons 2nd+
4%
GP-NonCons 1st1%
Where do we need to get to?
…to boldly go…
NHS Plan
“By December 2008 no one
will have to wait longer than 18 weeks
from GP referral
to hospital treatment”
Principles
• Patient experience – no hidden waits
• Simplicity, clarity & transparency
• Consistency with NHS Plan pledge
• Reinforcing positive behaviours in providers & commissioners
• Resilience – future proof in patient-led NHS with more Choice & plurality
• Data burden on NHS
Definitions…
Key issues
Clock starts? Clock stops?
Scope – services, patients?
OP & diagnostics
IP
Measurement & audit?
Scope: includes -1
• Referrals from: – consultants to consultants - agreed by “1o care”, unless “urgent”!– GPSIs– General Dental Practitioners– Optometrists – A&E, Minor Injuries Unit, Walk-in-centre– GUM– National screening programmes– Other primary care profs - when PCTs choose!– “mechanisms locally”
• Referrals to consultants working in community (incl. employed by PCT)
• Endoscopies - OP or DC!
“…from GP referral to hospital treatment”
Scope: includes -2
Clinically complex cases, including tertiary referrals, Choice & multi-org pathways:
• No suspensions
• No reset for provider cancellations
• % tolerance
• …..audit? “By December 2008 no one will have to wait longer than 18 weeks..”
Scope: excludes - 1
• Direct access: – Diagnostics pre-decision to refer– Physiotherapy– Occupational Therapy– Speech & language Therapy
• Podiatry & Audiology if not consultant-led
• Referrals to nurse consultants & AHPs
Clock start -1
• At point of booking (no re-start if wrong clinic) • Intermediate services (CAS, GPSIs, RMS) – at
GP ref if part of 2o pathway, not of 1o
• Direct access diagnostics (1o&2o) – when patient books 2o OP appointment
• If planned sequence, new pathway when medically fit for each stage
• Patient choose “late” appointments – undecided?
Clock stops -1• Start treatment – “1st curative/definitive
treatment”?! (not admission for diagnostics )
• Admission & treatment as IP/DC (not cancelled ops)
• OP (incl AHP) – procedure
• Return to 1o care after OP/diagnostics & no further 2o care action
• Medical device fitted
Clock stops -2• Patient declines treatment or dies• “Watchful waiting/active monitoring” starts• DNAs
– 1@1st appointment & back to GP….but CAB– @ follow-up ….in tolerance
• Other patient-initiated delays (e.g. repeated failures to agree date …but ?“reasonable offers”) - in tolerance
• When in doubt: “will be rules” or in tolerance!
Average waits by consultant: General Surgery, LTHT, March 2006
-
20.0
40.0
60.0
80.0
100.0
120.0
140.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
We
ek
s
IP component
OP component
18
Average waits by consultant: T&O, LTHT, March 2006
-
20.0
40.0
60.0
80.0
100.0
120.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Wee
ks
IP component
OP component
18
Inpatient waiting list reductions - main surgical specialties
NHS Yorkshire and the Humber
5,3007,500
4,250 4,900
16,500
9,900
0
5,000
10,000
15,000
20,000
2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Service Implications
• Clearing the ‘backlog’
• Booking & scheduling pathways
• Patient flows – 1o, ISTC, 2o , 3o , 4o
• Pathway management
• Capacity planning & management
• Transition & parallel running
• Clinical engagement
Informatics issues
…just a few…
Information issues
• Clinician recording – OP outcomes, intentions, 1st curative treatment…
• Patient admin processes & recording
• Integrating information along pathways
• Pathway identification & linkage
• NHS data model
• PAS, diagnostics & other systems
Data model
Organisation
Staff group
Setting
Administrative
Process
Patient
Clinical
Outcome
Shifting the focus from
Systems: current PAS context
• Central returns/admin - centric: – Retrospective & paper-driven– Consultant orientated– Care setting insularity….
• 1990s front-ends, 1980s thinking, & 1970s data & business model
Systems requirements
• Patient-centred & pathway oriented • Pro-active scheduling & booking• Integrating “OP”, Diagnostics & “IP” • Cumulative PTLs• Link information across organisations &
professional groups
• By mid 2007 at the latest!
Reducing the burden
Monthly:
By PCT
Stocks
Flows: OP/IP
= 300 returns/month
Accountability
Supporting delivery X!
Conclusions…
…ICT disabled change…
From here…
A&E
Outpatients
Inpatients
Primary Care
ISTC
Mental
Health
AdministrativeRetrospectivePaper driven
…to here?
The patient
Who
Where
Why
When
What
By whom
How
Prior risk
Outcome: expected & actual
Clinical workflow
Booking
Scheduling
Real time
Resource planning
Interactive
Virtual linking of information (not systems)
…via…
• Agility – policies, organisations, patient wants….
• Business disciplines in a political world • Informatics integral to policy development • Business process redesign, ICT-enabled• Supplier capacity & partnership• Financial investment & affordability• HI workforce planning & professionalism
Key lessons from 18 weeks
• Excellent intent
• Spotlights long-recognised weaknesses in the NHS data model and core system
• Major strategic informatics challenge to CFH, the IC, suppliers and the NHS
• Informatics a policy afterthought
• Focus on monitoring not delivery
• We have about 18 months left….
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