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Clinical responses to the downturnSeven medical specialties address how they can help tackle the NHS financial challenge
JMCCJOINT MEDICAL CONSULTATIVE COUNCIL
Produced in partnership with
the voice of NHS leadership
The Joint Medical Consultative CouncilThe JMCC brings together the organisations that represent the medical profession in the UK. We provide a constructive forum in which our members can meet, debate and unite on the issues that affect the practice of medicine and the delivery of healthcare in the UK. We therefore aim to:
act as a voice for a united medical profession•
influence policy and inform the wider public debate•
engage with key stakeholders and build partnerships •to add real value.
www.jointconsultantscommitee.org.uk
The Academy of Medical Royal CollegesThe Academy of Medical Royal Colleges promotes, supports and facilitates the work of the Medical Royal Colleges and their Faculties. It has a leading role in the areas of doctors’ revalidation, training and education and aims to speak with a clear and sure voice on generic healthcare issues for the benefit of patients and healthcare professionals.
www.aomrc.org.uk
The NHS ConfederationThe NHS Confederation is the only independent membership body for the full range of organisations that make up today’s NHS. We represent over 95 per cent of NHS organisations as well as a growing number of independent healthcare providers. Our ambition is a health system that delivers first-class services and improved health for all. We work with our members to ensure that we are an independent driving force for positive change by:
influencing policy, implementation and the •public debate
supporting leaders through networking, sharing •information and learning
promoting excellence in employment.•
www.nhsconfed.org
The British Medical AssociationThe BMA is an independent trade union and voluntary professional association, which represents doctors and medical students from all branches of medicine all over the UK. We have a membership of over 143,000 worldwide. We promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.
www.bma.org.uk
Contents
Foreword 2Howtoreadthisreport 3 Neurosurgery 4Geriatrics 9Vascularservices 13Pathology 17Orthopaedics 28Neonatology 32Dermatology 36
Clinical responses to the downturn 04
Dr Mark Porter, Chair, Consultants Committee, British Medical Association
Professor Sir Neil Douglas, Chairman, Academy of Medical Royal Colleges
Professor Hugo Mascie-Taylor, Medical Director, NHS Confederation
Dr Alan Russell, Chairman, Joint Medical Consultative Council
ForewordTheoneconstraintwesetwasafirmfocusonthepracticeandbehaviouroftheirownspecialty’smembers–theareainwhichtheyhavethemostauthority.Onlyattheveryendofeachmeetingdidweallowashortperiodtodiscusswhattheyfeltotherpeoplecoulddotoaddressthechallenge.
Weweredelightedandsurprisedattheeasewithwhichwewereabletoengagewithorganisations.Notoncedidanygrouprefusetoparticipate.Theenthusiasmthatweencounteredwasdrivenbyadesirebytheparticipantstoshowleadershipinacrisisandawillingnesstotakeariskinrecommendingthingsthatevensomepeoplewithintheirspecialtywouldnotnecessarilyagree.Wecommendtheirlong-sightednessinseeingthatclinicianscanonlyprovidethebestpossiblecareiftheresourcesavailabletotheNHSareusedwell,andthatwasteanywhereinthesysteminevitablymeansamorelimitedorworsequalityservice.
Weseeourmethodandthisreportasafirststage.Therearemanymorespecialtieswecouldhaveengagedwithinthisproject,andindeedwhichhavealreadyapproachedus,butwewantedtopublicisethefindingsfromtheinitialphasetohearwhetherourapproachhasbeenvaluableornot.
WeencourageyoutogetintouchwithJontyRoland([email protected])toletusknowyourthoughtsonourfindingsandhowyouusethemtodrivemoreefficientservicesinyourorganisation.
TheNHSfacesthemostprolongedperiodoffinancialconstraintinitshistory.Inthenextfouryearsitneedstofind£15–£20billionofsavingsatthesametimeastacklingunderlyingincreasesinthecostsanddemandforhealthcare,andmanagingoneofthebiggestreorganisationsinitshistoryaswell.
Numerousinitiativesareunderwaytotrytoidentifywheremoneycanbesaved,yetfeedbackwereceivedsuggestedthatveryfewofthemwereengagingdoctorsinanymeaningfulway.ItisclinicianswhocommitmostoftheNHS’resourcesandfeelresponsibleforthecaregiventoindividualpatients.
Thepremiseofthisprojectisthatwhenchangeneedstohappenrapidly,inevidence-basedandhighlysensitivefields,itisbesttoasktheexperts:thosewhoprovidetheservicesfirsthandandseeboththevalueandthewastemostdirectly.
Wethereforedevelopedaverysimplemethodology:toassemblegroupsofdoctorsfromaseriesofspecialtymedicalsocietiesorRoyalCollegesandinhalf-dayworkshopsaskeachofthemtoanswerthefollowingquestion:
“How can practitioners in your specialty help to release NHS resources while maintaining or enhancing quality?”
Theywereaskedtodrawontheircombinedexperienceandknowledgeoftheevidenceintheirspecialty,butalsoencouragedtomakecreativesuggestionsbasedontheirexperience.
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Clinical responses to the downturn 05
How to read this reportbulletpointstyle,andshouldbereadassuch,whilesomehavebeenexpandedintofullprose.Wearesatisfiedwiththisdiversitybetweenthespecialties,astohomogenisethemwould,webelieve,havelessenedtheirpower.Ithasalsoallowedeachchaptertocoveraverybroadrangeoftopicsinasmallnumberofwords.
Weadviseyoutoreadthisreportasatooltoguideandinformthediscussionsaroundcostefficiencyweknowtobetakingplacelocallyandnationallyalready.Wehopethatwithitthesediscussionscanbenefitfromgreatercollaborationbetweenmanagersandcliniciansandcanprotect–perhapsevenimprove–qualityofcareduringthedownturn.
Inproducingthefollowingchapterswehaveattemptedtohaveaslittleauthorialinputaspossible.Wewantedtotransmittheexpertiseoftheparticipantsfromeachspecialtyinaspureaformaswecould.Ourroleinthefocusgroupswastofacilitateandrecordthediscussion,afterwhichwesenttheparticipantsasummaryoftherecommendationsthatweremade.Eachgroupthenengagedinaniterativeprocessofdebatingandamendingtheirsummaryviaemailuntiltheyweresatisfiedwiththefinalproduct.
Asaresultofthisprocess,thechaptersdonotfollowasetformat,butvaryconsiderablyinform,lengthandstructure.Someremainina
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Clinical responses to the downturn 06
NeurosurgeryThe following recommendations were produced by the British Society of Neurological Surgeons to highlight where resources could be released in NHS neurological services, while maintaining or enhancing quality.
neurosurgeon).Theseteamsmeettorapidlyreviewthelistofreferralstoaneurosurgeryunitand,onconsideringtheGP’snotesandanyscansthathavebeeninitiated,decidewhethertoaccepttheappointmentdatethathasbeenmadeorwritebacktostatewhy–onthestatedsymptoms–aspecialistappointmentisnotnecessary.
Someareashaveencounteredproblems•withthisinnotbeingabletorejectappointmentsmadeunderChooseandBook.Onewayaroundthisistoarrangedummyappointmentsthroughtriage,andthesecanbeacceptedorrejected.
AsimilarsystemtotheabovecouldbeusedforvettingGPs’accesstoimaging,withasmallpanel,includingaconsultantneurosurgeon,quicklyreviewingthenacceptingorrejectingreferralstoMRIorCTscans.
Alternatively,furthereconomiescouldbemadebyusingaprimarycare-basedtriagesystem,wherebyunlessaspecialistopinionisspecificallyrequestedalessqualifiedindividualthanaconsultantneurosurgeonmakesdecisionsonreferralsbasedonmutuallyagreedguidelines.
Locallyobservedimpactsofintroducingsuch•asystemincludeasubstantialimprovementintherateofpeopleseenbyaneurosurgeonwhowentontobeoperatedon.
Thereisahighincidenceofunnecessaryreferralfromjuniordoctorsduringnightshifts.Nationalprotocolsforjuniordoctorsonwhentorefertoaconsultantneurosurgeoncould
Themes
Referral•
Pre-admission clinics•
Emergency admissions•
Discharge•
Follow-up•
Procurement•
Single-use items•
Culture•
Reduction of changeover time in theatres•
Other areas of variation in practice that could •be harmonised
System-wide issues•
Referral
Thereareasignificantnumberofunnecessaryreferralsfromprimarycaretoneurosurgicalunits.
Therearemethodsoftriagingavailablethatwouldmakereferralmoreefficient.
SomeneurosurgicalunitshavesetclearreferralcriteriainpartnershipwiththeirPCTsandlocalGPswiththeeffectofreducingunnecessaryreferrals,yetthisisnotconsistentlypracticedacrossthecountry.
Anothertechniquethatisused,whichiseffectivebutnotuniversal,ismulti-disciplinarytriageteams(whichincludeaconsultant
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Clinical responses to the downturn 07
bedevelopedwiththesupportoftheBritishSocietyofNeurologicalSurgeonsandusedtoreducethiscostandincreasethequalityofcare.
DistrictgeneralhospitalsnotperformingMRIsatnightisarelatedcauseofunnecessaryreferraltoneurosurgery.AhighpercentageofurgentMRIsarenegative,showingthereisscopetoreducethenumberbeingtransferredtoneurosurgicalunits.
Fromasystem-wideperspective,thelackofanationalimagetransfersystemcreatesunnecessarywastageoftimeandresources.Thisisparticularlythecaseinneurosurgeryasitisaheavilyimagedependentspecialty.
Pre-admission clinics
Goodpre-admissionclinicsreducethenumberofcancellations,complications,delayeddischargesand,ultimately,lengthofstay.
Goodpracticeinpre-admissionisnotuniversal,sothisneedsre-emphasising,perhapsbasedaroundthefollowingfourfactors:checkingtheindicationissensible;ensuringthepatientissafetoundergoanaesthesia;makingsurethatallthelogistics(includingcorrectkit)areinplace;andensuringthereisthoroughdischargeplanning.
Betteradherencetobestpracticeinpre-admissioncouldbesupportedeitherbytheproductionofachecklistand/orbyaspecialistnursebeingassignedtomicro-managethekeyfactorsabove.
Thecoreaspectsofpre-admissionclinicplanningcouldbedoneoverthephonemoreoftenthaniscurrentlythecase,savingjourneysandtime.
Thereisaneedtoensurethatthosedoingpre-admissionclinicsaresufficientlysenior,whichshouldhavetheeffectofreducingon-the-daycancellations.Thepossibilitycouldevenbeexploredofhavinganaesthetistsleadtheclinics,asispracticedinpartsoftheUSA.
Cleareraccountabilityisneededforthecheckingofbloodresults.Thepre-admissionclinicshouldberecognisedasprimarilyresponsibleforthis.
Emergency admissions
Separatingemergencyoperationsfromelectiveoneswouldallowsmoother,moreefficientrunningofelectivelistswithoutinterruptions.
MoreflexibilityinthelengthofworkingdaysandSaturdayworkingwouldallowgreateruseofavailablefacilities.However,thiscouldonlybedoneafterinvestigatingwhetherincreasedstaffingcostsmightunderminethesavingsthiswouldachieve.
Ofthemselves,suchchangeswon’tsavemoney,butgiventhatthefinancialcrisisisprimarilydrivenbyrisingdemandandcostsratherthanareductionincash,suchchangescouldsavefurthercapitalexpenditurelateron.
Discharge
Gettingpatientsdischargedwellisasignificantchallenge,andadriverofconsiderableunnecessarycost.
Publishingexpectedlengthsofstayforparticularconditionswithinaunitwouldgiveallstaffanunderstandingofwhattoworktowards.Thiscouldevenbeexpandedtosomethingencompassingmanyunits–orevennationally–toallowbenchmarking.However,if
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Clinical responses to the downturn 08
usedonawiderscaletherewouldhavetobeagreaterdegreeofflexibility(intheformofastandarddeviation).
Specificdischargedatescouldbeagreedforindividualpatientswhentheyareadmitted.Allstaffontheunit(andthepatient)wouldknowtheseandbeexpectedtoworktowardsthem.Theprocesscouldevenbetakenonestepfurther,withdetailedcareplanningforeachpatientstatingwhatshouldbehappeningeverydayfromthefirsttothelastdayofstay.
Theuseof‘departurelounges’cancreatemoreefficientuseofbeds.Theseareroomswherepatientscangofrom8amontheirdayofdischargesothattheirbedismorerapidlyfreedup.
Follow-up
Repeatedfollow-upsandin-personfollow-upappointmentsareoftenunnecessaryusesoftime,moneyandtravel.
Morefollow-upcouldbedonebytelephone,whereappropriate.
Perhapsastandardofonepost-surgicalvisitfollowedbyphonecontactcouldbeagreed,unlessanindividualsurgeoncandemonstratetopeerswhytheywishtovaryfromthisnorm.
Morefollow-upcouldbeledbyphysiotherapistorspecialistnurses.
Procurement
Shunts–itisestimatedthatbetweentenand15modelsarecurrentlyinuseamongstneurosurgeons,yetbeyondprogrammableversusnon-programmablethereisno
evidencethatoneisbetterthananother.Ifstandardisedtoasmallnumbertheycouldbeprocuredmorecheaplyandwithnoadverseeffectonquality,solongasvariationfromthiswaspermittedifitwaspartofatrial.
Spinalimplantsvaryhugelyinprice–from£500to£10,000–yetitisquestionablewhethertheyarenecessaryatalland,eveniftheyare,whethertherangecurrentlyinuseneedstobeaswide.
Thereisalsoscopetoreducethenumberofinstrumentsthatarepurchasedas,inreality,therearemoreavailabletothesurgeonthanareused.Consultant-levelinvolvementindecisionstocloneparticularinstrumentscouldreducethis.
Somedevicescouldberemovedfromtheatrealtogether.Evidenceshowsthereisalowerriskofinfectionfromsuturescomparedtostaples,yetstaples–whichcostmore–arestillinhighlevelsofuse.Theoptionshouldberemoved,atleastforsmallwounds.
Single-use items
Themodelsusedtoassesstheriskofprioninfectionfrominstrumentsarenon-evidence-based.Theyarefoundedonestimated,notionalrisksthatsinceimplementationhavesubsequentlybeenreviseddown.Yettherehasbeennochangeinthepolicy.
TheseregulationsareonlypracticedintheUKanddriveunnecessaryuseofexpensive,single-useitems.
ThecostsofcurrentprocedurestominimiserisksofCJDinfectionare,therefore,disproportionatetothesizeofthatrisk.
Thecurrentregulations,eveniftheywere
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Clinical responses to the downturn 09
justified,areunfeasibletoimplement–particularlyinstrumenttracking.
Culture
Increasedteamworkinginrecentyearshashadapositiveeffectonimprovingconsistencyofpracticebetweenindividualneurosurgeons.
Thereis,however,aprevalentcultureofacceptingwasteinthetheatreenvironment.Thereneedstobearealisation,fromconsultantsthroughtotechnicians,thattheirbehaviourandhabitsdirectlyaffectthebudgetaryhealthoftheirunit.Neurosurgeonscouldsupportazerowastemessageacrosstheunit,hospitalandtrust,perhapsaspartofawidernationalinitiative–“Youwouldn’tacceptwastelikethisathome!”.
Reduction of changeover time in theatres
Inadequatesupportforanaesthetistsisoneofthemajorcausesofdelays.Thissupporthasworsenedoverthelastdecade.
Theregulationthatanaesthetistsarenotallowedtofunctionwithoutanoperatingdepartmentpractitionerpresentisunnecessaryandcausesfrequentdelays.
Moreefficientporteringarrangementswouldallowforearlierstartsandfasterchangeovers.
Anothermajorcauseoftheatredelaysisnotstructuralorprocedural,however,butcultural.Thementalityofoperatingtheatresispermissiveoflateattendanceanddelays.Neurosurgeonsshouldseektocombatthis,bothintheirownhabitsandintheirleadershipoftheatreteams.
Other non-evidence-based areas of practice that could be harmonised
ThefrequencyofMRIscansforfollow-upoftumoursisvariable.Aneffectivemodelmaybeavailable,whichcouldbedisseminatedthroughneuro-oncologycancernetworks,reducingthefrequencyforsometumourtypes/agesofpatient.
Whom,whenandhowoftentoscreenforfamilialaneurysmsvariesunnecessarily.InputfromtheBritishSocietyofNeuroradiologistscouldhelpwiththis.
Bestpracticeinpost-coilingradiologyfollow-upcouldbeclarifiedwithinputfromtheNeuro-InterventionalGroup.TheremaybeinformationfromtheISATfollow-upstudywhichcouldinformauniformpolicythatiscost-effective.
Outpatients
Itispossibletodesignfacilitiesforoutpatientsthataremoreflexibleandallowgreaterefficiency,particularlyintheuseofbedsandwithtransfersbetweenoutpatientsandinpatients–forexample,day-caseunitsforinvestigationssuchasangiogramsandminorsurgery,oralternativevenuesforwardattenders,shuntreprogrammingetc.
System-wide issues
Thecostofsimplesurgicaldevices(suchasscrews)couldbeloweriftheexcessivedegreeofregulationaroundthemwasremoved.
Ifincentivescouldbedevisedtogivecliniciansmoreofastakeandinvolvementinthefinancesoftheirunit,thiscouldhaveasignificantimpactonthecultureofwaste.
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Clinical responses to the downturn 010
Fromasystemsperspective,therearestilldelayscausedbysocialservicesnotbeingsufficientlyresponsive.Therewassupportforasystem,inplaceinsomelocalities,wherebythecouncilpaysforanyadditionalcosttothehospitalfromdelayeddischargepastacertaindelay.
TheEuropeanWorkingTimeDirectiveisamajorcauseofwasteandchaotic
Workshop participants
Mr Paul Eldridge, SBNS Hon. Sec and consultant neurosurgeon in Liverpool
Mr William Harkness, SBNS Council Member and consultant paediatric neurosurgeon (GOS)
Mr Philip van Hille, Immediate Past President, SBNS, and consultant neurosurgeon, Leeds
Mr Alistair Jenkins, SBNS Council Member and consultant neurosurgeon in Newcastle
Ms Anne Moore, SBNS President and consultant neurosurgeon in Plymouth
Prof John Pickard, Professor of Neurosurgery in Cambridge
Mr Owen Sparrow, Chair of SAC in Neurosurgery and consultant neurosurgeon in Southampton
practices,particularlythroughhavingtouseconsultant-deliveredservicesovernightforconditionsandproceduresthatdonotrequirethatlevelofexpertise,makingthemlessavailableforspecialistworkinthedaytime;andalsoinincreasedtimespentonhandoversthatareineffective.
Morerapidemergencypatienttransportationwouldreducepatientmorbidity.
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Clinical responses to the downturn 011
GeriatricsThe following recommendations were produced by the British Geriatrics Society (BGS) to highlight where resources could be released in NHS geriatrics services, while maintaining or enhancing quality.
Prior discussions had already taken place between the England Council and the UK Management Committee of the BGS, whose ideas fed into this meeting.
whichparticularkindsofpatientscouldbeimmediatelytriaged.
Theservicewouldbeforfrailolderpeopledisplayingsignsoftypicalcomplexco-morbidities.Triagecriteriawouldnotbeage-basedandwouldnotdivertthosewithsevereconditions(suchaschestpainorfracturedneckoffemur)totheteam.
Theteamwouldhavecloselinkstocommunitycarecolleaguessuchasintermediatecarenursesandwouldaimtogetpatientssupportedtogohomemuchmorequicklythanhaspreviouslybeenpossible.
Thiscouldeitherbeimplementedasaninvest-to-savescheme,meaninghighercostsintheshorttermtorealiselowercostslateron,or,giventhestrengthofevidenceofpositiveoutcomesfromsimilarmodelsinternationally,1couldbereconfiguredfromexistingresourcesinlargerdepartments.
‘Best buy’ 2: People should not go into permanent care without a comprehensive geriatric assessment by a team led by a geriatrician and, where possible, done in the community
Thenumberofpeoplegoingpermanentlyintocarehomesisunnecessarilyhigh.Asthisisaveryexpensiveoptionforpublicservices,thereneedstobeproperpolicingtoensureappropriateplacement.
Comprehensivegeriatricassessments(CGAs)offerthepossibilityoffindingmorecreativeways
Themes
‘Best buy’ 1: A geriatrician-led team at •or near the front door of every admitting hospital
‘Best buy’ 2: People should not go into •permanent care without a comprehensive geriatric assessment by a team led by a geriatrician and, where possible, done in the community
‘Best buy’ 3: Advance care planning•
Medicines management•
Recognition and treatment of delirium•
Virtual clinics and telephone consultations•
Frequency and expense of litigation•
Integration•
More efficient working practices•
Other examples of best practice•
‘Best buy’ 1: A geriatrician-led team at or near the front door of every admitting hospital
ThereisanincreasingnumberofolderpeoplepresentingtoA&Edepartments,someofwhomaredischargedwithouttheirunderlyingproblemidentified,andsomeofwhomareadmittedbutkeptwaitingunnecessarily.
Ratherthanwaitinguptofourhourstoseeajuniordoctor,aspecialistteamledbyageriatrician(andpreferablyinaphysicallyadjacentunit)couldbeonhandandto
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Clinical responses to the downturn 012
tosupportpeopletocontinuelivingathome,yetarenotroutinelyperformedpriortocarehomeadmission.
CGAsarecurrentlydoneinhospitals,butthisputsoffsomepeoplewhodislikethesetting.Establishingcentresincommunitysettings,suchascommunityhospitals,wherethiscouldbedonewouldincreasethenumberofpeoplecomingforward,reducingthenumberadmittedtoresidentialandnursinghomecare.
Anycostgeneratedbythiscouldberecoupedfromthereallocationofintermediatecarebudgets,whicharesub-optimalinmany,thoughnotall,areas.
Whileitiscurrentlyunclearexactlyhowthiscouldwork,securingcloseinvolvementfromGPconsortiawouldbebeneficial.Thismightbeanearlyareaforconsortiatoconsidercommissioningininnovativeways.Ensuringadequatespecialistinputfromgeriatriciansinthisisimportant.
‘Best buy’ 3: Advance care planning
Thisisanexampleofbestpracticethatisnotyetroutineamonggeriatricians.
Advancecareplanninginvolvestabulatinginformationaboutthepatient’swishesonappropriatenessofadmission,investigation,intervention,rehabilitationandendoflife.Thisinformationisstoredinawaythateverybodyhasaccessto.Palliativecarecolleagueshavealreadydonemuchoftheworktodevelopthismodel.
Thiswouldensurethatresuscitationwouldnotbeattemptedincaseswhereitisinappropriateandagainstthepatient’swishes.
Itwouldalsoreduceinappropriateemergencyadmissions,toomanyofwhicharegeneratedbyacarehomenotknowingtheperson’swishes,
callingtheout-of-hoursserviceandleadingtoahospitaladmission.Insomecasesthiscanleadtosomeonespendingtheirfinalhoursinhospitalratherthanathome.
Theprocessofhowtobuildadvancecareplanningintotheexistingpathwayneedssomemorediscussion.Isdischargeplanningtherighttimetohavesuchconversations,oristheclinicafterwardsbetter?Eitherway,itisimportantthatanexistingrelationshipisinplace.
TheBGS’roleinthiswillbetoencouragetheuptakeandspreadoflearningamongstitsmembers,andtoworkwithleadersinthecarehomessector,wherethebiggestopportunitiesforimprovementexist.
Other recommendations for more effective use of resources
Medicines management
Itishopedthattheadventofelectronicprescribingwillreducethenumberofadverseeventsduetodruginteractions.
Amoreimmediateopportunityexiststoreducesomeofthemorecommoninappropriateprescribingerrorsthataremade,throughazerotolerancedrivetowardsdrugrecording–alldrugchartsmustgiveastopdateforadrug,andallmuststatethepatient’sallergies.
Theproblem,intheviewoftheBGS,isnotalackofpharmacologyknowledge,butalackofbasicsystemstosupportpractice,andlaxadherencetopracticesthatdoexist.
ThedevelopmentbytheRoyalCollegeofPhysiciansofanationaldrugchartisstronglysupportedbytheBGS,andtheBGSwillendeavourtobackupitsimplementationbydisseminating
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Clinical responses to the downturn 013
aculturefromthecentrethatitisunprofessionalnottorecordmedicationproperly,includingastopdate.TheBGScallsonemployersandregulatorstojoininwiththisaswell.
Thesechangeswouldreducecostsboththroughaloweroveralldrugsbillandthroughreductioninmedicationerrorsleadingtotheneedforfurthertreatment.
TheBGSisalsosupportiveofsystemssuchaspatientpassports,whichwouldenablerecordsonapatient’smedicationandallergiesandasynopsisoftheirmedicalproblemstobeobtainedinamoretimelyfashion.
Recognition and treatment of delirium
Deliriumispoorlyunderstood,oftenunrecognisedandinadequatelymanagedinhospitals,yetitisasignificantfactorinextendedlengthsofstayandmortality.
Simplemeasures,ifmorewidelyused,wouldpreventmanycasesofdeliriumoccurring.AnongoingstudybyHoltandYoungisdemonstratingsuccessfulresultsfromtraininghealthcareassistantsandwardnursestorecogniseandpreventdelirium.
ThiscouldbepackagedasabestpracticepublicationbadgedbytheBGSanddisseminatednationally.TheBGShasproducedclinicalguidelinesondelirium,whichinclude76keyreferences.TheseareavailableontheBGSwebsite(www.bgs.org.uk)under‘Clinicalguidelines’(Clinical guidelines for the prevention, diagnosis and management of delirium in older people in hospital).
Virtual clinics and telephone consultations
Thesearebestforpeoplewithsinglesystemproblems,forexamplediscussingcarotiddopplerresults,ratherthanforpatientswithmulti-systemdisordersandfrailty.
Frequency and expense of litigation
GeriatricianscouldmakeacontributiontoreducingthelitigationbillintheNHSbybeingmoreawareofthemaincausesofpay-outs.TheBGSwillthereforeproduceapostcardadvertisingthetoptenreasonsfordefenceclaimsingeriatricsanddisseminatethistoitsmembers.
Integration
Whilenotadirectcostsaving,therisksaroundforthcomingverticalintegrationsintheNHSinEnglandmaydriveincreasedcosts.TheBGScouldthereforeproduceaguidetowhatworkswellforolderpeoplewhenintegratingvertically.
InseekingtoimproveGPskillsandcontinuityofcarebetweengeriatricsandprimarycare,geriatricianscouldconsiderresurrectingoffersofdomiciliaryvisits.Thesewouldhelptoreduceunnecessaryadmissions,althoughunlikeinthepasttheyshouldn’thavefinancialincentivesattachedtothem,andtherewouldneedtobeclearstandardsonwhentheyshouldbeused.Iffounduseful,domiciliaryvisitscouldevenbegivendedicatedtimeinthegeriatrician’stimetable.
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Clinical responses to the downturn 014
More efficient working practices
Hospitalworkingisstillsometimesconfiguredarounda9to5,fivedaysperweekmodelthatisnolongersustainablewiththelevelof24/7demand.TheBGSrecognisestheneedforthismodeltochange,andbelievesthatgeriatricianswillplaytheirfullpartalongsideotherspecialtiesinsupportingthistransition.
Other examples of best practice
Rapidaccessclinics,forexamplefortransientischemicattacks(TIA)–theseexistandarecost-effective,butarenotuniversal.
Interdisciplinaryteams–geriatriciansshouldreviewtheskillmixoftheseteamsasinmanyareasthediversityhasbeensignificantlydiminished.Thisisoneofthedriversofunnecessarilylonglengthofstay.
Inrecentyearsgeriatricianshavemadesignificantprogressexportingtheirskillsinthecareofolderpeopletoorthopaedicsurgeons.TheBGSnowintendstoattempta
Workshop participants
Dr Ian Donald, BGS member
Prof Graham Mulley, Immediate Past President
Dr Mehool Patel, BGS member
Dr Linda Patterson, BGS member
Dr Tarun Solanki, BGS member
similarapproachtootherdisciplinesofsurgery.Throughthisproject,alinkwillbeestablishedwiththeVascularSociety.
Therearepresentlyfewopportunitiesforgeriatricianstobenchmarktheperformanceoftheirdepartmentsagainsteachother.Usefulmeasurescouldincludethenumberoffallsinhospitalorthenumberofpatientswithdiarrhoea.Discussionsareongoingnationallyaroundestablishingclinicaldashboards,andtheBGSissupportiveofthese.TheBGSisalsosupportiveofthemovetowardsoutcome-focusedmeasures,andhasalreadydevisedsomeoutcomemeasuresforgeriatrics,whichitwillbeginpromotingandwhichhavebeenincludedinitsresponsetotheconsultationonoutcomemeasures.
References
Caplanetal:‘Arandomised,controlledtrial1.ofcomprehensivegeriatricassessmentandmultidisciplinaryinterventionafterdischargeofelderlyfromtheemergencydepartment–theDEEDIIstudy’,J Am Geriatr Soc.2004Sep;52(9):1417–23.
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Clinical responses to the downturn 015
Vascular servicesThe following recommendations were produced by the Vascular Society to highlight where resources could be released in NHS vascular services, while maintaining or enhancing quality.
wouldgivethebenefitsofcostandqualitywhilemaintainingappropriatelevelsofaccess:
Highlycomplex,high-risk(andcostly)surgical1.procedureswouldbelimitedtofourorfivespecialisedunitsinEngland.Forsomeprocedures,suchascomplexendovascularaneurysmrepairs(EVARs),thiswouldbewithaviewtotheirrollingoutmorewidelyovertime.Others,particularlythoseoflowvolumeandhighrisk,suchasthoracoabdominalrepair,wouldremainlimitedtotheseveryfewcentres.
Proceduresofmediumcomplexity,such2.asinfrarenalaorticaneurysms,carotidendarterectomy,lowerlimbrevascularisationandamputationsforlimbischaemia,wouldbedonein40to50vascularunitsnationally–afurtherhalvingofthecurrentnumber.Theseunitswouldoffera24/7servicebasedaroundeighttotenconsultantseach.Protocolsandqualitytargetswouldbesettoensurethatallpatientsservedbyanetworkreceivedequalandtimelyaccesstothecaretheyneed.
Proceduresoflowcomplexity,suchas3.diagnosticultrasoundandcross-sectionalimaging,angiography(someangioplasty),varicoseveinandvascularaccesssurgery,wouldbeprovidedinmosthospitals.Inaddition,clinicswouldberuninallhospitalswithineachnetwork.Inthiswaythecentral(hub)hospitalwouldprovideservicesinanoutreachmannertosurroundinghospitals.Thecentrewouldhaveresponsibilityforcaredeliveryagainstagreednationalandlocalservicelevelagreements.Thiswouldresultinmostpatientcontactwith
Themes
The structure of vascular services nationally•
More consultant-delivered care•
Discharge planning•
Demand management•
Outcome-based standards•
Procedures of low or questionable value•
Theatre overruns•
Procurement•
The structure of vascular services nationally
Manyunnecessarycostsinvascularsurgeryderivefromextendedlengthsofstay.Reducingtheserepresentsaclearareawherecostefficiencyandqualitycanbeimprovedsimultaneously.
Remodellingvascularservicesbyreducingthenumberofproviderswouldreducemortalityandmorbidityaftermajorvascularsurgerybyconcentratingmedicalandnursingexpertise,increasingunitvolumesanddrivinggreatersystematisation.Thecostsinvolvedinthecentralisationofserviceswouldbeoffsetthroughimprovedoutcomesbyreducingthecostofpost-operativemorbidityandhencelengthofstay.
AfirstphaseofremodellinghasalreadyresultedinthenumberofvascularunitsinEnglandbeingmorethanhalvedtojustover100.
Thisremodellingneedstocontinueintoafurtherphase,leavingathree-tiersystemwhich
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Clinical responses to the downturn 016
vascularservicesoccurringintheirlocalhospital,neartotheirhomes.Thepatientwouldonlytraveltothecentreforcomplex,hightariffinterventions.Staffingofoutreachservicesmightuselocallybasedstaffunderthesupervisionofspecialistsfromthecentre,ensuringlocaldeliveryoftraining.Thiswouldalsoestablishlinksattheclinicallevelbetweenthecentreandoutreachservices.
Anadditionalbenefitofthisthree-tiermodelisthatvascularsurgerywouldmapmuchmorecloselytothecurrentstructureofcardiacsurgery.Giventheoverlapbetweentheseareas,therewouldbescopetoshareinfrastructureinfuture,resultinginamoreefficientuseofresources.Theintroductionofhybridtheatresisoneexampleofgoodpracticeinthisarea.
RealisingthisremodellingwillrequiretheVascularSocietytointensifyitseffortsinsettingouttoitsmembersthebenefitsofmovingtothisnewsystem.TheVascularSocietywillneedtodescribehowworkinginbiggerunitswillimproveefficiencyandpatientsafetywithoutcompromisinglocalhospitalcaredelivery.TheVascularSocietywillneedtosecurethesupportofhealthleaderstoreassuresmallerhospitalsthatitwon’tleadtotheirlosingoutontheirabilitytoperformothersurgicalproceduresthatrequiresupportorinputfromvascularsurgery.
Anotherchallengeistoproduceastructureforthetrainingofjuniordoctorsthatmapstothisnewmodel.TheVascularSocietywillbehappytocontributetodevelopingthis.
More consultant-delivered care
Thereisscopetoimproveworkingpatternsinvascularsurgeryunitstomakebetter
useofexistinghumanresourcesandmaptheprovisionofservicesmorecloselywithpatternsofdemand.Inparticular,makingmoreeffectiveuseoftheconsultantsinunitswouldbringbothcostandqualitybenefitswithoutneedingextrastaff.Examplesare:
takingoneconsultantperweekoutof•electivecareandontothewardtoberesponsibleforthewardround
patientmanagementtoenablerapid•dischargewhereappropriate
juniordoctortraining•
betterlistmanagementforurgentreferrals.•
Consultant-deliveredcarewillhelptoreducelengthsofstay.Inaddition,therewouldbeefficienciesaroundimprovedprioritisationofwork.Readyaccesstoemergencyoperatingtimewouldreducethewaitforsurgeryformanypatientsastherewouldbeanidentifiedspecialistavailabletoperformthenecessaryprocedures.
Everyvascularunitwilloperatea24/7consultanton-callrota.Theon-callteamshouldhavea24/7presenceinthecentralhospital,withclearwrittenprotocolsformanagingemergenciespresentingtootherhospitalswithinthenetwork.
Thereisaneedtodevelopspecialistteamworkingbetweenvascularspecialists,radiologistsandanaesthetiststoimproveefficiencyandpatientsafety.ThereisevidenceofgoodpracticeintheUKandthisshouldbemorewidelyadopted.
Betterplanningofhigherriskprocedureswouldallowbetterallocationofscarceresources(forexample,criticalcarebeds).Specialistsshoulddevelopcarepathwaysthatdescribehowcarewouldbedeliveredforthesecasesandhowpatients’needsforcriticalorhighdependencycarecanbebestmanaged.
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Clinical responses to the downturn 017
Discharge planning
Thereisaneedforthewidespreadadoptionofproperdischargeplanningamongstallvascularunits,includingconsultantinputintopre-assessmentanddischargeplanningmeetings.Improvedpre-assessmentalonecouldallowallpatientstobeadmittedonthesamedayastheiroperation,regardlessofitsseverity.
Theuseofsame-dayadmissionreduceslengthofstayandcanprovidesavingsinthenumbersofbedsneededtorunaservice.
Anothermodelthathaspotentialtobespreadmorewidelyistheestablishmentofprotectedbedstodrivehigherthroughputforcertainconditions.Protectedbedsforangioplastyhave,whereused,resultedinsurgeonscompletingagreaternumberofcasesperday.
Bedsoutsideoftheacuteunitforrehabilitationandlowintensitycarewouldalsohelptheappropriatelevelofcaretobedeliveredcost-effectively.
Demand management
Thereisaneedformoreproactivestrategiesbyvascularsurgeonstomanageoutpatientdemandforcommon,minorconditionssuchasminorvaricoseveinsandintermittentclaudication.Thiswillfree-upconsultanttimeformanagingmorecomplexproblemsinatimelymanner,whilemakingbetteruseofexistingresources.
CooperationbetweenlocalvascularsurgeonsandGPstodevelopandshareclearreferralprotocolsisoneofthemosteffectivewaysofmanagingdemand.
Oneunitthatdidthiswaseventuallyabletocloseoneofitstwowardsbecauseoftheextentofthereductioninoutpatientdemandthatwasachieved.
Outcome-based standards
Professionalstandardsareoneofthemosteffectivewaysofdrivingimprovementsinpracticeamongstvascularsurgeonsnationally,improvingqualityandcost-efficiency.AllvascularspecialistsneedtosubmitalloftheirindexcasestonationalauditusingtheNationalVascularDatabase.
Criticaltotheseisthedevelopmentofcarepathwaysthathaverobustoutcome(aswellasprocess)measures.Theseneedtobeco-producedwithpatients.TheVascularSocietyisintheprocessofdevelopingseveralofthese,andwillendeavourtousethemasameansofimprovingpatientsafetyandsatisfactionwithcare.
Procedures of low or questionable value
Thereareareasofclinicalpracticeamongvascularsurgeonsthatvaryunnecessarily,orwhereproceduresaredoneonthebasisoflimitedorquestionableevidence.Inthesecasesstandardisationcouldresultinlowercosts.
SeveraloftheseareasshouldbeconsideredprioritiesforfurtherupdatesofNICEguidelines.TheVascularSocietywillencouragevaricoseveinsinparticulartobereviewedassoonaspossible,basedonthehighvolume,andhencecost,oftheseprocedures.Currently,referralpracticesandinterventionratesvarywidelyacrosstheUK.
Intheinterim,theVascularSocietywouldbewillingtoproduceguidelinesonwhenvaricoseveinsurgeryshouldbeprovidedontheNHS.Therearesomecaseswhereevidenceshowsitisclinicallyandcost-effective(suchaswithpatientswhohavehadulcers)butcurrentlyaccessvariesinawaythatisnotrational.
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Clinical responses to the downturn 018
Alternatively,guidelinescouldbedrawnuplocally,assomelocalPCTs,GPsandvascularunitshavedonealready.
Theatre overruns
Feweroverrunsinsurgicaltheatreswouldresultinincreasedcapacityandgreaterefficiency.
Onewayofachievingthiswouldbetoextendthedurationoftheatrelists.Currenttimesarenotparticularlygoodforvascularsurgery,withfinishestypicallyscheduledaround4:30to5:00pm.Extendingthisto6:00pm–theso-called‘threesessionday’–maybebetter.
Staggeringthestarttimesoftheatresalsomaybemoreefficientandavoiddelays,aswouldgreateruseofweekendsforelectivework.
Whileoutsidetheinfluenceofvascularsurgeonsalone,theestablishmentofleaguetablesforlatestartsamongsurgeonsinaunithavebeenfoundtoimprovetheirkeepingtotime.Vascularsurgeonsshouldsupportsuchlocalmeasures
thatobserveandfeedbackbehaviourswhichimprovethepracticalaspectsofcare.
Procurement
Thereisscopeforincreasingeconomiesofscaleinprocurementthroughjointworkingbetweenvascularsurgeryandotherspecialties,particularlyasprovisionbecomesmoreconcentrated.
Sharedprocurementwithcardio-thoracicsurgeryinparticularshouldbeexploredbysurgeonslocally,particularlyaroundhybridtheatres,high-endimagingandanaesthesia,aswellasnursingandcriticalcare.
Theover-regulationofbasicdevicesresultsinveryhighcostsforrelativelysimpledevicessuchasendovascularstentgraftsforaorticaneurysmrepair.Thereispossiblysomescopeforvascularsurgeonstoagreetofurtherlimitthenumberofthesedevicesavailable(althoughtherangeisalreadyfairlysmall)orformanufacturerstoagreetoasetprocedurepriceinordertocontinuesupplyingtotheNHS.
Workshop participants
Professor Jonathan Beard (Consultant vascular surgeon, Sheffield)
Mr John Brennan (Consultant vascular surgeon, Liverpool)
Professor Nick Cheshire (Consultant vascular surgeon, Imperial)
Mr Jonothon Earnshaw (Consultant vascular surgeon, Gloucester)
Mr Ashok Handa (Consultant vascular surgeon, Oxford)
Miss Linda Hands (Consultant vascular surgeon, Oxford)
Mr Richard Holdsworth (Consultant vascular surgeon, Stirling)
Mr Peter Lamont, President of the Vascular Society (Consultant vascular surgeon, Bristol)
Mr David Mitchell (Consultant vascular surgeon, Bristol)
Professor Cliff Shearman, Immediate Past President, the Vascular Society (Consultant vascular surgeon, Southampton)
Mr Mike Wyatt (Consultant vascular surgeon, Newcastle)
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Clinical responses to the downturn 019
PathologyThe following recommendations were produced by the Royal College of Pathologists to highlight where resources could be released in NHS pathology services, while maintaining or enhancing quality.
inManchesterinJune2010.Theopeningtopicwas‘ThechangingNHSenvironmentandtheimpactonpathology.’Aninteractivequizshowedthatover50percentofthelabmanagersattendinghadnotheardofQIPP.
TheNHSConfederationcontactedtheCollegeinJanuary2010tosuggestthattheorganisationsworktogetherwithotherhealthcarepartners.Afocusgroupwasheldon24August2010toexploretheexistingareasofreformingactivity,progresswithimplementationandidentifywherefurtherworkwasneeded.
Intheinterim,andinanticipationofthecoalitiongovernment’swhitepaper,Equity and excellence: liberating the NHS,theCollegepublisheditsownstatementonpathologyservicereconfigurationinJuly2010.1
Severalthemesemergedfromthegroupwhichmeton24August.
Intelligent requesting
“Ifwecouldstopdoingunnecessarylaboratorytests,wecouldatastrokemakeefficiencysavingsthatareprobablygreaterthanthosethatarecurrentlybeingdemanded.However,toooftenlaboratoriesfinditeasiertodoatestthantoarguethatitisnotnecessary.”1
In‘defaulttesting’,tick-box-stylerequestformsnudgeclinicianstowardsdoingmoreteststhanisnecessaryandencourageahabitoftickingalltheboxeswithoutthinking.Someteamsevenpre-prepareformsinadvancewithalltheboxestickedbeforeseeingthepatient.
Themes
Intelligent requesting•
Workforce profiles and training•
Efficiency and productivity•
Openness on performance•
New developments and molecular testing•
Intelligent commissioning•
Information technology and •disintermediation
Clinical leadership in pathology•
Who should do what?•
Background
TheRoyalCollegeofPathologistshasbeenhelpingtokeeppathologyprofessionalsinformedandinstepwithfinancialchallengesfacingtheNHS.ThisisparticularlyimportantgiventheprominencegiventoLordCarter’sreportsonNHSpathologyservicesinQIPP(Quality,Innovation,ProductivityandPrevention),withQIPPworkstreamsineverySHAledbytheSHAmedicaldirectors.InDecember2009,theassistantregistraroftheCollegewasgiventhetaskofprovidingalinkbetweenthePathologyClinicalDirectorattheDepartmentofHealthandtheCollege’sprofessionalmembershipinaddressingthefinancialchallengesaheadforpathologyinathoughtful,clinicallysoundandeffectiveway.
TheneedforlaboratorymanagerstobebetterinformedoftheQIPPagendawashighlightedataSiemens-sponsoredmeeting
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Clinical responses to the downturn 020
In‘activerequesting’,cliniciansmustwriteontherequestformtheteststheywishthelabtodo.Thisleadstosignificantreductionsindemand,withnonoticeableeffectonqualityofcare.
Alternatively,‘problem-based’requestingmodelsencourageclinicianstostatequestionsthattheywouldlikeansweredaboutthepatient,andthepathologistthendecideswhatteststhisjustifies.
InSalisbury,whenthereasonforrequesting•thyroidfunctiontestswasintroducedratherthansimplyrequestingthyroidfunctiontests,theuseofanalgorithmenabledanappropriateresponse.
Oneareathatusedthismodelsawa25per•centreductioninthenumberoftestsneeded.Italsoledtothereportsgeneratedbythelabbeingmorerelevantandcomprehensibletotheclinicianastheyansweredthequestionposed.
Therearealsospecificissuesaroundtheoveruseoftestingbydoctorsintraining,forwhomitisoftenamedicalcrutchwithtestsperformed‘justincase’whenthedoctor’sknowledgeoflaboratoryinvestigationisinsecure.Thereductionofbasicscienceandpathologyinmedicaleducationandtrainingneedstobeaddressedandreversed.Thisproblememphasisestheneedforanational‘formulary’oflaboratorytests,givingauthoritativeguidanceinamanneranalogoustotheserviceprovidedbytheBritishNationalFormularyfordrugs.ThiswasrecommendedbyLordCarterbutisstillunderdevelopment.
Duplicaterequestingforthesamepatientiscommon.Aneffectivewayofreducingthisistorequiretheuseofapatient’sNHSnumberinthetestingprocess,supportedbyITsystems
thatcanidentifyandflagduplicatetests;yet20percentofpathologylabsdonotroutinelyusetheNHSnumberandthereisfrequentlynocompulsiononrequestors.
OnelocalstudyofanA&Edepartmentfoundthat10percentofthetestresultsrequestedbyjuniordoctorswereneverlookedat.Thisisaclearareaofbothresourcewastageandpoorqualityofcare.Inbloodsciences,whereurgentcasesmaybeidentifiedatrequesting(ifITsystemsallow),thelabmaybeabletocheckwhetherahighpriorityresulthasbeenviewedafterareasonableperiodoftime.Ifthereisnorecordthatithasbeenaccessedwithinareasonabletime,theconsultantshouldbenotified.
Pointofcaretesting(POCT)hasenabledmoretestingtobedoneoutsidethelaboratoryinwaysthatmaybemoreconvenientforthepatient.Itisoftennotthecheapestoption,however,andthequalityofPOCTisvariable.ThereshouldbecompliancewithMHRArecommendationsintheuseofPOCT,includinglinkswithapathologylaboratorytoensureproperqualityassurance.TheCollegewouldsupporttheintroductionofamandatoryaccreditationschemetoaddressthispatientsafetyissue.Theevidenceonthecost-effectivenessandclinicalutilityofPOCTforsomeindicationsisunclearandwarrantsfurtherinvestigation,particularlyifitleadstoduplicatetestinginthecentrallabasclinicalcolleaguesarereluctanttotreatpatientsontheevidenceprovidedbyPOCTalone.
•Feedback of performance informationtorequestingclinicians,whetheritbeauditinformationabouttheirrequestingratesorinformationabouttheappropriatenessoftheirtestordering,hasbeenshowntoleadtomorerationalrequesting.
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Clinical responses to the downturn 021
Clinician education• canbelabourintensive,butiftargetedintheformofguidelinesorassociatedwithperformancefeedbackcanleadtomoreappropriatetestrequesting.1
ItwasoncecommonpracticeforlocallabstoproduceoccasionalreportstoGPsontheirrequestingratesbenchmarkedagainstothersinthelocality.Benchmarkreportswereaneffectiveandlow-costwayofrapidlychanginghighrequestingGPs’rates.Thereisaprogrammeindevelopmenttointroducethisnationally,andtheprogressofthisworkstreamneedstobeclarifiedanditsroll-outfullyfunded.ThestudyoftheprofileofpathologyservicesbyNHSLondonrevealedastrikinglydisproportionateriseinrequestsfromGPswhencomparedtotheriseintheacutehospitalsetting.Thereasonsforthisareunclearasyetbutworthfurtherinvestigation.
Anumberofpathologytestsnotuniversallyavailableinallpartsofthecountrycanbeusedinplaceofmoreexpensiveimagingtestsandareexamplesofevidence-basedclinicalpractice.Theimprovedqualityofcareresultingfrommanyofthesetestsincludesareducedneedforoutpatientappointments.NHStrustmanagersmaybereluctanttoacceptthisreductionbecausefewernewoutpatientappointmentsmeanalowerincomefromthatsource.Theirargumentfailsontwocounts:theoverallcostoftheservicerisesifpatientsarereferredforunnecessaryconsultationandprocedureswithoutreasonedselection;andpeopleareconvertedtodependentpatientsinappropriately.ExamplesincludeBNPforpossiblecardiacfailure(obviatestheneedforanechocardiograminmanycases)andfaecalcalprotectinforinflammatoryboweldisease(canavoidtheneedforcolonoscopyandexpensiveimaging).FiftypercentoflabsdonotofferBNPandveryfewlabsofferfaecalcalprotectin,despiteaNICEguideline.Labs
thathaveintroducedsuchtestshavemadeverysignificantsavingsfortheirhealtheconomies.However,asthesavingsarenotmadeinpathologyitisdifficultforpathologiststobuildbusinesscasesforimplementationunilaterally,especiallywherethesavingsrelyonareductioninactivityinanotherdepartment.
Wherelocalpathologistsareinregularandclosecontactwiththeircolleaguesintheacutehospitalandinthecommunity(GPsinparticular)theyareeffectiveinspreadingthiskindofbestclinicalpractice.Thisisrelativelylessdifficultinnon-metropolitanareasthaninourinnercitieswherethechallengeisgreater.InanygivenareaoftheNHS,however,itdoesrequiretheparticipationofmorespecialtiesthanpathologyandtheattentionandinterestofNHSmanagers.TheNHSConfederationandtheCollegewillpushmessagesactively,throughthisprojectandusingappropriatemediaoutlets,suchastheHealth Service Journal.2ThereisaclearneedtoworkcloselywithothermedicalRoyalCollegesandspecialtysocietiesinordertoagreemaximumorrationalrequestingforcommonconditionsandclinicalpresentations.Suchguidelinesdoexistbuttheirimplementationispatchyandinadequate.
Workforce profiles and training
“Alaboratorythathasinadequatelyskilledstaffcannotdeliveragoodservice.However,alaboratorythathasanexcessofskilledstaffcannotdeliveranefficientservice,andefficiencyisanimportantaspectofquality.
“Maintainingstaffskillsincludestrainingnewstaff.Organisationsthatchoosenottoemployandsupporttraineesmustnotbeallowedtoapplythispolicytogainacompetitiveadvantage,orthelong-termstabilityoftheservicewillsuffer.”1
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Clinical responses to the downturn 022
Somelabshavebeencreativeintheirapproachtoworkforcechangeswhileothershavebeenmoreresistant.Thereisaneedfortraditionalrolestochange,manualrepetitivetaskstobetakenonbystaffatlowergrades,andinnovationinlaboratorywaysofworkingtoreleasecostsavings.
Changesmustbeapproachedsystematically.Oneapproachthathasbeenusedtogoodeffectistheperformanceofa‘pertestaudit’.Thisinvolvesproducingabreakdownofthetasksrequiredforeachcommontest,workingoutwhichstaffcapabilitiesandstaffgradesarerequiredtodoeachofthesetasks,calculatingthecostperhourofthisandthereforearrivingattheoptimumstaffmixforaparticularlab.Thefocusofchangesshouldgenerallybeonthefunctionalityrequired,notonspecificstaffgroupswhichcanbeadistractionandleadtoinappropriateskillmix.
Laboratoriesshouldnotbetooreadilycriticisedforbeingriskaverseasthetime(andoftentechnological)investmentrequiredtoappraise,train,supportandcertificatechangesinworkforceshouldnotbeunderestimated.Workforcedevelopmentplansshouldbeforfivetoten-yeartimehorizonsandthesupportofpathologyandseniortrustmanagementmustbesustained.
Majorchangescannotbeimplementedintheshortterm,however.Theywillneedcarefulplanningasextendedrolesgenerallyrequiretrainingandappropriatebackfill.Moreimmediatechangesmaybepossibleoutsideofthelab.Someareashavesuccessfullytrainedhealthcareassistants(HCAs)inclinicsandonwardsinphlebotomyandPOCT.ThisdevelopmentrequiresHCAcapacitytosupportit,butcansignificantlyreducetheburdenonmoreexpensiveclinicians.ThecreationofmultifunctionalHCArolesenhancesmotivation
andflexibility.Nurse-ledanti-coagulantclinicsmakebetteruseofresourcesthanconsultant-ledbutarenotyetuniversal.Therearealsopatientself-testingschemeswhichhavepotentialfornationalroll-out.
Thereisuncertaintyabouttheplaceoftraineemedicalstaffasworkforceintheprovisionofpathologyserviceswhenfundingstreamsarebeingcutoratleastmodified,specialtytrainingnumbersarebeingcutorfrozen,thecommissioningandprovisionoftrainingprogrammesisbeingreformedinthemostradicalwayinthehistoryoftheNHS,andthefuturepositioning,structureandfunctionofpostgraduatedeaneriesisunclear.Similarly,theimpactoftheproposedchangesimplicitintheModernisingScientificCareersprogrammeontheavailabilityandutilityofbiomedicalscientistsandclinicalscientistsastheyprogressthroughtheircareerpathwayisalsounclear.Thislackofclarityneedstobeaddressedurgently.
Efficiency and productivity
“Ahigh-qualitylaboratoryservicemustbeefficient;otherwise,inaresource-limitedservice,itisusingresourcesthatcouldbenefitpatientsinotherways.Althoughtheargumentisself-evident,thisfactorhastoooftenbeenomittedfrommeasurementsofqualityintheNHS.
“Guidanceandprotocolsthathavebeendevelopedinthepastexclusivelyonthebasisof‘bestpractice’,withoutexplicitlyconsideringefficiencyorresourceuse,shouldbereviewedwithcost-benefitanalysisinmind.”1
Onanindividualbasisthereisvariationintherateatwhichconsultantpathologistsworkin
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Clinical responses to the downturn 023
termsoftestvolume.Someofthelowerratesareduetopathologists‘over-processing’byspendinglongeronindividualcasesthanisclinicallyrequiredorevenjustifiable.
Historicallyithasbeendifficultforlocalmanagerstoeffectivelychallengethisbehaviourbecausethereisnoconsensusaboutwhatareasonablecaserateis.The‘new’consultantcontractalsomakesaddressingproductivitydifficultsinceitstipulatestimespentatwork,notproductivityormeasurementofoutcomes.
TheRoyalCollegeofPathologistsproducedguidanceonHistopathologyofLimitedClinicalValue,withrecommendationstostopsome‘routine’examinations;3however,itisnotclearwhateffectthispublicationhashadinpractice,becauselaboratoriestendtocomplywithclinicalrequestsfortestingeveniftheclinicalneedforthetestisnotexplainedorjustified.
Whenprocessmanagementandsub-specialisationisintroducedinhistopathology,productivitymaybeimprovedalongwithquality.4
TheRoyalCollegeisengagedinare-analysisoftheCollegeworkloadunitsithaspublishedforhistopathologyandthisshouldassistintheconsiderationofadequatecase-rateparameters.ItisacknowledgedthatsomeCollegeguidelineshaveresultedinanincreaseinworkloadwithinhistopathologylaboratoriesinanattempttoimprovequalityandthatproductivityandefficiencymayhavebeensecondaryconsiderations.
Inallpathologydisciplinesefficiencyandproductivityarenotjustaboutwhathappensinthelab,orevenpre-selectionandpost-resultinterpretation.Muchpathologyclinicalconsultationconcernsdiscussionwith
non-laboratoryprofessionalsaboutpatientmanagementasadirectconsequenceoftheinterpretationofaresult.TheessentialnatureofthisconsultationismostobviousintheworkofthehistopathologistandthejointworkingoftheCalmanCancerMDT.Itisonlyslightlymoresubtleinotherspecialtiesbutitisdifficulttoseehowotherdoctorscanworkassafely,effectivelyandefficientlywithouttheguidingopinionsandadviceoftheirlocalchemicalpathologist,haematologistormicrobiologist.Takenforgranted,andneverobjectivelystudiedormeasured,thisisaninvaluableexpertresourcetotheNHS.
Openness on performance
“Theonly‘real’testofthequalityofamedicallaboratoryserviceisitseffectonpatientoutcomes.Anythingelseisasurrogatemeasure.Directmeasurementofaneffectonoutcomesisrarelypossible,sosurrogatemeasureshavetobeused,buttheirlimitsmustbeunderstoodandasuitablespreadofmeasuresisessential.”1
TheCollegewelcomesmovestodeviselaboratorykeyperformanceindicatorsandmakethesepubliclyavailable.Transparencycanbeausefultoolinimprovingvariousaspectsofthequalityandefficiencyofcare,andpublicationoflaboratoryexternalqualityassuranceschemeresultsisoneexampleofsuchtransparency.
WherelaboratoryExternalQualityAssessment(EQA)dataaremadepublic,theCollegewillworktosupportthisandtomakesurethatinformationisreleasedinaformthatisasmeaningfulandcomprehensibleaspossible,allowingcommissionerstomakebettercomparisonsoflaboratoryperformance.However,itiswastefultodemandanalytical
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Clinical responses to the downturn 024
accuracythatisfarinexcessoftheaccuracythatisneededinclinicalpractice,sotheCollegehasestablishedaprojecttoattempttodefineMinimumAnalyticalPerformanceStandards(MAPS).
Someexternalqualityassuranceschemes,especiallyinhistopathology,assessindividualpathologistperformanceratherthanoveralllaboratoryperformance.Thisisrelevanttomedicalrevalidation,butmaynotbeameaningfulmeasureofoveralllaboratoryqualitybecausedifficultcaseswouldnormallybesubjectedtointernalconsultationbetweenpathologists.CareisthereforeneededintheinterpretationofEQAdata.
TheCollegeissupportingon-goingworktodevelopstandardisedoutcomes-focusedmetrics.TheCollegeandDepartmentofHealtharesupportinganumberofworkstrandsonstandardisation–MinimumAnalyticalPerformanceStandardsfortests,HarmonisationofReferenceRangesanddevelopmentoftheNationalLaboratoryMedicineCatalogue(standardisationofnamesofanalytes,coding,unitsofmeasurementandsuitabilityforcombinationfromdifferentsources).Thecataloguewillultimatelydeliverthe‘nationalformularyforlaboratorytesting’recommendedbyLordCarter.Itsassociatedguidanceontestusewillfacilitatethedevelopmentofexpertdecisionsupportsystemsthatshouldmaketheuseoflaboratorytestsmoreefficient.Theseworkstreamsdeservecontinuingcentralsupporttoachievelaboratoryoutputsthatarecomparableforcommissioners.
Inaddition,sothattherecanbeassurancethatthequalityofcaregivenbyeachlaboratoryismaintainedduringtheperiodofNHSreorganisationandafterwards,theCollegewillassistwherepossibleintheproductionofqualityindicatorsforpathology.
TheCollegehasalreadymadeavailableanexampleofaservicespecificationforcommissionersofpathologyservicestoinformthecreationofregionalandlocalspecifications.5
New developments and molecular testing
“Newinvestigationsshouldbeevaluatedonthebasisnotonlyoftheiranalyticalvalidityandclinicalvalidity,butalsoontheirclinicalutility.Clinicalutilityincludesacost-benefitanalysis,wherecostsandbenefitsshouldbeevaluatedbytheimpactofthenewtestonthewholepatientpathway,notmerelytheimpactwithinthelaboratory.”1
TheRoyalCollegeofPathologistsisdevelopingadviceonastratifiedapproachtothedevelopmentofmoleculartesting,crucialforqualityinhighlyspecialiseddiagnosticservices.6
Thereisastrongpushfromtheirmanufacturersfortheuseofmoremoleculartests,yetmanyarenotnecessaryorareunproven.Giventhisconflictofinterest,andthatknowledgeaboutthesetestsamongstpathologistsisvariable,purchasingofthesetestsshouldbepartofspecialistcommissioningwithaclearevidencebaseforimplementation.
Thepotentialofmolecularteststofocusclinicalresourcesandimprovebothqualityandefficiencyofhealthcareinthefutureisanimportantreasonforprotectingtheskilledworkforceandacademicresourcesofpathology.
Intelligent commissioning
“Aprovidershouldnotbeallowedonlytoofferarestrictedrangeofcommonlyused
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Clinical responses to the downturn 025
tests,withtheexpectationthatadifferentcontractwithadifferentproviderwillcovermoreesotericneeds.LordCarterrecognisedthatthe‘cherry-picking’ofhigh-volumetestscoulddestabilisetheprovidersofesoterictests,totheultimatedetrimentofpatients.”1
Asaprofession,pathologists–includingtheRoyalCollege–arekeentoworkwithGPcolleaguesintherunuptoGP-ledcommissioning.Partnershipworkingwillbeimportantifthetransitionistobesmooth,qualityofcareprotected,andimprovementsintheirknowledgeofthespecialtymade.Pathwaymappingwillbeacriticaltoolinservicedevelopmentandpathologistswilltakeanactiveroleinthis.
CertainspecialistpathologyservicesintheUKareprovidedbyasmallnumberoflaboratoriesandspecialistsandhavepoororunder-prioritisedsuccessionplanning.IftheseservicesaretoremainintheUK,thereneedstobemorelocalsupportforthesesmallerservices.
Toensureoptimalpatientcare,itisessentialthatcontractsforlaboratoryservicesallowlaboratorystafftoinitiate‘reflextesting’,whereanunexpectedlaboratoryresultimmediatelyjustifiesfurthertestingofanyresidualsample.Toinsistongoingbacktotheclinicianandthepatientbeforeundertakingthefurtherinvestigationcancausedelay,confusionandharm.Theethicsofreflextestingmustalwaysbeconsidered,butitisusuallyjustifiedbytheobservationthatpatientsnormallyrequestinvestigationoftheirillness,notlimitingconsenttomeasurementofaspecificanalyte.
InarecentarticleinThe Times,ChrisHam,theCEOoftheKing’sFund,raisedconcernsabouttheeffectsofthecommissioningplanslaidoutinthecoalitiongovernment’swhite
paper:“Ministersshouldrecognisetheneedtosupportcollaborationinsomeareaswhilepromotingcompetitioninothers.Improvingresultsforpatientswithcancerorstrokevictimsrequiresformingnetworksofhospitalswillingtoconcentrateservicesinfewercentres.Rulesmakingitdifficultforspecialistnetworkstodevelopbecausetheyareanti-competitivewouldworkagainsttheGovernment’saims.”7
Information technology and disintermediation
“TheoperationalsuccessofrationalisationofpathologyserviceswillbeheavilydependentonefficientandreliableIThomogeneityandconnectivitywithinanygivennetwork.Completeuniformityofreferencerangesandunitsofmeasurementandreliablemethodsforidentifyingpatients(ideallyNHSnumber)areobviousprerequisites.”1
Developmentsininformationtechnologycontinuetoallowimprovementsinthequalityandefficiencyofcare.
Thereareofcourseimplementationcosts,butelectronicrequestingandreportingsystemscandecreasetranscriptionerrorsandenablesampletracking.Decisionsupportsystemsembeddedintheorderingsystemcanbelinkedtocarepathwaysandcanintroduce‘rules’onfrequencyoftesting.Asnotedabove,thishasthepotentialtogenerateconsiderablecashsavingsaswellasimprovementsincare.UsingITforreportingacrosslaboratoryandclinicalnetworksandspecialistlaboratorieswillspeedreceiptofresultsandgeneratecashsavings.
SuchdevelopmentsrequiretheconsistentuseoftheNHSnumberastheuniquepatientidentifierandthecompletionanduptakeoftheNationalLaboratoryMedicineCatalogue.
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Clinical responses to the downturn 026
Clinicalpathologyprofessionalscanusepathologytestresultstotriggerappropriateactions,forexampledetectionofacutekidneyinjuryandearlydetectionofliverdisease.
Standardisationofpathologydataenablesitsusewithinclinicalnetworks,withindiseaseregistriesandforsecondaryuses,includingresearch.ThePathologyFuturesGrouphasidentifiedmanyareaswherethecarepathwaycouldbeclarifiedandspeededupifthelaboratorywasencouragedtointeractdirectlywiththepatient.8
TheRoyalCollegeofPathologistsandtheRoyalCollegeofGPshaveissuedstatementsonthedeliveryoflaboratoryresultsdirectlytopatients.9Thisisnotappropriateinallcircumstances,butitisanticipatedthatsuch‘disintermediation’wouldfree-upthetimeofotherclinicians,particularlyGPs,enablepatientempowermentintheirlong-termconditionsandhencegainhigherpatientsatisfaction.
Leicester’smodelofdirectpatientcontactforthyroidreplacementtherapyisagoodexampleofthisworkinginpractice.Directreferralbyhistopathologiststocolposcopyclinicsbasedoncervicalcytologyfindings(directreferral)isanother.
Oneregularcomplaintfromtraineesonrotationbetweendifferenthospitals,evenwithinthesameregion,istheinefficientwasteoftheirtimecomingtogripswiththeheterogeneityoftheITsystemswithoutwhichtheycannotworkandlearn.
Clinical leadership in pathology
“Reorganisationandconsolidationofmedicallaboratoryservicescanofferconsiderablebenefits,butthecomplexityof
thetaskmustnotbeunderestimated.Itisthereforeessentialthatpathologists,whobytheirworkunderstandsuchcomplexityandhavethebestinterestsofthepatientsatheart,provideleadershipinthisproject.”1
TheRoyalCollegeofPathologistshasbeenprovidingguidanceandsettingstandardsfortheprofessionsince1962andanationalpathologyclinicaladviserwasappointedbytheDepartmentofHealthin2004.
ThedesireforimprovedclinicalleadershipinpathologywasstatedbyLordCarterofColesinhisfirstReport of the review of NHS pathology services in England,publishedin200610andreiteratedmorerecentlyinhissecondreport,publishedlatein2008.11Alsoin2008thethenHealthMinister,LordDarzi,putclinicalleadershipatthecentreofhisNextStageReview.12
Inadditiontodriverswhichareexternaltopathology,intheprofessionthereisanappetiteforincreasedvisibility.ThedevelopmentofNationalPathologyWeekandtheCollege’spublicengagementprogrammereflecttheperceptionwithintheCollegethattheprofileofpathologyneedstobeimproved.
AsmallleadershipgrouphasbeensetupintheCollege,ledbyitsvice-presidentsDanielleFreedmanandTimWreghitt,andincludingIanFrayling,RachaelLiebmannandRichardHerriot.
InNovember2009,anemailwascirculatedtoallthoseaffiliatedtotheRoyalCollegeofPathologistsintheUKaskingthemtoparticipateinanelectronicsurvey.Almost600responseswerereceived,ofwhichalmost100percentfeltthatclinicalleadershipcan‘makeorbreakpathologyservices’.
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Clinical responses to the downturn 027
Again,almostallrespondentsfeltthattheCollegehasaroleinthedevelopmentofclinicalleadership,buthalftherespondentsfeltthattheCollegedidnotcurrentlygiveadequatesupporttoclinicalleadership.
TherewasaverystrongfeelingthattheCollegehasaroleindevelopingandpromulgatingtheconceptofleadershipinitsfellows,bothcurrentandfuture.ThisissomethingthattheCollege,withtheguidanceoftheleadershipgroup,iscommittedtoproviding.13
ApilotprogrammeofpathologyleadershipdevelopmentsetupbytheDepartmentofHealthin2009wasinitiallytakenupbytwoSHAs–WestMidlandsandSouthEastCoast.Theprogrammerecruitedscientists,managersandmedicsinpathologyandinvolvedaseriesofintensecoachingsessionswitheducationinboththeoryandpracticalstrategiesforleadership.Feedbackfromtheparticipantswasuniversallypositive,andthepilotculminatedinpresentationsinJuly2010atpresentationandawardsceremoniesheldinKentandatWarwicktomarktheachievementsofallparticipants.TheprogrammeisbeingrolledouttoafurtherthreeSHAs,withdiscussionson-goingaboutleadershipdevelopmentcoveragemorewidely.
“Thereconfigurationofpathologyservicesisachallenge;buteverychallengeisaleadershipopportunity.”1
Who should do what?
Theareasdiscussedatthismeetingwerewide-ranging,andimplementingthechangesdiscussedwilldemandtheinvolvementofmanygroups.Thiscomplexitycouldleadtoparalysisiftheneedforsharedactionisnot
recognised.Wethereforesuggestthefollowinganalysis.
Group A. Activity largely within the practice of pathology
Workthatpathologistscan(andshould)dowithinthecompassofourownspecialtiesorworkplace.Thismaybeoflittleinteresttoanyoneelsesavetotheextentthatitimprovesthequality,safetyandcost-effectivenessoftheservice.Activitiesinclude:
productivity•
disintermediationandharmonisationoftests•
workforcere-profiling•
informationtechnology(someaspects).•
Group B. Activity at the interface with clinical care
Someofthiscanbeachievedwithinpathologydepartments,butmuchwillrequiremajorchangesinclinicalbehaviour,withoutwhichtherearefewpracticalbenefits;soagreementswithstaffoutsidepathologydepartmentsareessential.Behaviourmodificationrequiresresources.Activitiesinclude:
demandmanagementinprimarycare•
demandmanagementinsecondarycare•
useofresults•
informationtechnology(someaspects)•
opendata•
markertests•
POCT.•
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Clinical responses to the downturn 028
Group C. Activity that integrates into the clinical QIPP pathways
Amorecomplexareatouchedoninthediscussionbutnotexplicitinthediscussion.Thisincludestheuseofpathology(testsandexpertise)toreducehospitaladmissions,expediteearlydischarge(cuttinglengthofstay)andfacilitatethepatientpathwayinthemanagementoflong-termconditionsandintheelectivecarepathway(admissions,lengthofstayandoutpatientappointmentscanallbereducedwithashiftinthelocationofcaretowardsthecommunity).
Group D. Activity that requires political/commissioning input from pathologists locally and from the Royal College nationally
Merelyaddressingtheshort-termqualityandproductivitychallengesofthedownturnwillfailboththeNHSandthepublicinthelongtermunlessattentionispaidtofuture-proofingtheservice.Thiscanbechallengedbyshort-termcommercialinterests.AgoodexampleistheinternationalcommissioningofreportingofcervicalsmearsintheRepublicofIreland,whichalmostcausedirreversiblede-skillingoftheentirecountry.
Actionsincludeensuringthatthecommissioningprocessincludesconsiderationof(andallocationoffundingtosupport):
specialist(regionalornational)pathology,•includingmoleculartesting
teachingandtraining(ofclinicalaswellas•labstaff)
researchanddevelopment.•
Contributors
DrNeilAnderson,CDofCoventryandWarwick•PathologyNetwork–ClinicalBiochemistry
DrIanBarnes,NationalClinicalDirectorfor•Pathology,DepartmentofHealth–ClinicalBiochemistry
DrJulianBarth,President,ACB–Clinical•Biochemistry
DrBillBartlett,NinewellsHospital,Dundee–•ClinicalBiochemistry
DrGiffordBatstone,NationalClinicalLead•forPathology,OCCO,NHSCfH–ClinicalBiochemistry
DrBernieCroal,AberdeenUniversityMedical•School–ClinicalBiochemistry
DrDanielleFreedman,Luton&Dunstable•Hospital,RCPathExec–ClinicalBiochemistry
DrIanFry,FrimleyParkHospital,Surrey–•ClinicalBiochemistry
MrPhillipHurley,LaboratoryManager,•BiochemistryandImmunology/TrustPOCTlead,HeartofEnglandNHSFoundationTrust
SamanthaJayaram,RCPathPressand•CommunicationsManager
DrSimonKnowles,YeovilDistrictHospital–•Histopathology/Cytopathology
DrRachaelLiebmann,Kent,RCPathExecand•ClinicalDirector,KentandMedwayPathologyNetwork–Histopathology
DrSuzyLishman,Peterborough,RCPathExec–•Histopathology/Cytopathology
DrAngusMcGregor,LeicesterRoyalInfirmary–•Histopathology
MrJeffSeneviratne,GreaterManchester•PathologyNetwork–ClinicalBiochemistry
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Clinical responses to the downturn 029
DrCharlesSinger,RoyalUnitedHospital,•Bath;RCPathExec–Haematology
DrSusanStewart,Cambridge,RCPathCouncil•–Histopathology/Cytopathology
ProfessorMikeWells,Sheffield,RCPathExec•–Histopathology
DrTimWreghitt,Cambridge,RCPathExec–•Virology
References
Reconfiguration of NHS pathology services: 1.a statement from the Royal College of Pathologists.www.rcpath.org/resources/pdf/reconfiguration_of_nhs_pathology_services.pdf
‘Thefutureofpathologyservices’.2. Health Service Journal,16Sept2010.
Histopathology of limited or no clinical 3.value.RCPathpublication.www.rcpath.org/resources/pdf/HOLNCV-2ndEdition.pdf
www.journals.elsevierhealth.com/4.periodicals/ycdip/article/S0968-6053(04)00082-1/abstract
RCPathsupportedservicespecification.5.www.pathology.plus.com/docs/PathServiceSpecKM.pdf
The future provision of molecular diagnostic 6.services for acquired disease in the UK.www.rcpath.org/resources/pdf/pubs_moleculardiagnosticservices_oct10.pdf
www.thetimes.co.uk/tto/opinion/7.columnists/article2756292.ece
www.laboratorymedicine.nhs.uk/8.labmedicine/Portals/0/PathologyFutures/Path_Futures_Vision_FINAL.pdf
StatementoftheRoyalCollegeof9.Pathologistsonthedeliveryofmedicallaboratorytestresultsdirecttopatients.www.rcpath.org/resources/pdf/rcpath_results_direct_statement_v12.pdf
LordCarterofColesFirstReport.10.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137607.pdf
LordCarterofColesSecondReport.11.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091984.pdf
LordDarzi’sNextStageReview.12.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf
‘Clinicalleadershipinpathology’,13. RCPath Bulletin,Oct2010.www.rcpath.org/resources/pdf/Oct2010bulletinclinicalleadershipinpathology.pdf
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Clinical responses to the downturn 030
OrthopaedicsThe following recommendations were produced by the British Orthopaedic Association and the British Orthopaedic Directors Society to highlight where resources could be released in NHS orthopaedics services, while maintaining or enhancing quality.
Discharge planning and length of stay
There is good practice in discharge planning amongst the best units, but significant variation – both between orthopaedic surgeons and the quality of local social services.
Enhanced recovery is being done in some form across the country, but could be done better.
Improvements could be made by having more active, consultant-level participation in multi-disciplinary musculoskeletal assessment clinics, alongside the other relevant professions (for example, social care and physiotherapy). Where problems are identified, they should be referred to the appropriate specialty (for example, geriatrics, anaesthetics or general practice) before they can go onto the surgical waiting list
A further development that would help would be if patients were not referred by their GP for consideration of surgery until they had undergone a fitness check in primary care. This could identify in advance those factors (particularly chronic diseases) that are likely to delay admission or discharge.
Improvements in this area could have a significant impact on costs, it was thought.
Pre-operative assessment
All patients coming for elective surgery should have a robust pre-operative assessment with input at an appropriate (i.e. consultant) level.
An unintended consequence of this that would
Themes
Discharge planning and length of stay•
Trauma •
Unnecessary referral•
Procedures of questionable value•
In-theatre efficiency•
Implants•
Cancellations•
System-wide issues•
BritishOrthopaedicAssociation
Context
Orthopaedics are behind most other specialties in meeting the 18 weeks target.
However, it began from a much lower starting point. Pathway redesign work so far has resulted in a 300 per cent improvement on June 2007.
Improvements beyond this point will be very hard, particularly with population changes and orthopaedics having the highest number of surgical admissions.
Current practice leads to a lot of short-term, expensive treatment being done just before the 18 week deadline, evening and weekend work etc. Such eleventh hour interventions are not sustainable, particularly with rising demand.
So a priority for the specialty is to do more surgery, more quickly, but in the present context it also needs to save money too.
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Clinical responses to the downturn 031
needtobeinvestigatedfirstiswhetherthesechangescouldgenerategreaterdemandforhighdependencybeds(forpatientswithmoresignificantco-morbidities).Thiscouldresultinmoreon-the-daycancellationsifthosebedsareunavailable.
Trauma
Traumasurgeryfororthopaedicsislikelytobeamorefertilegroundforcostsavingsthanelective.
Itishardtomanage,historicallyneglectedandunderfunded.Becauseoftheunpredictabilityoftraumaitcanbedifficulttomatchcapacitytodemand.
Traumaneedstobeallowedtobegivengreaterprioritybyorthopaedicsurgeonsandtheorganisationstheyarepartof.
Ingeneral,surgeons’jobplanningshouldnotmeanthattheydoelectivesurgerywhilsttheyareoncallfortraumaatthattime.
Itshouldbebothasurgicalandmanagerialaimtogetallpatients,includingthosewithfracturedneckoffemur,operatedonwithin48hours.Everyextrahourinbedraisescostandrisksofcomplications,whichleadtosignificantunnecessarycosts.
Unnecessary referral
KnowledgeoforthopaedicsamongstGPsisinadequategiventheproportionoftheirpatientsexhibitingorthopaedicproblems.Onesolutiontothiscouldbelocalorthopaedicsurgeonsmeetingwiththeirprimarycarecolleaguesandcommissionerstosetlocalguidelinesforwhattoreferandwhen,andwhattodobeforereferringetc.
MapofMedicinecouldbeusedtosupportthis,ashasbeendoneinDevonoverthelast18months.WorkisalreadyongoingtodevelopacompetencypackageonthemostcommonaspectsoforthopaedicstodevelopGPs’competencies.
Thereissignificantpotentialforsavingsthroughimprovedmusculoskeletal(MSK)services.Morerobustandefficientpathwayswouldensuretheappropriateuseofsurgerywhereindicatedandcouldsavetheuseofunnecessaryresources.
Onceapatienthasbeenreferredforanoperation,thereisadisincentiveforrefusingthisifitwouldbeofquestionablevaluetothem–ittakeshalfanhourtoexplaintothatpatientwhytheoperationwillnotgoahead,versusfiveminutestosayyes.Therefore,inprinciplethesurgicalteamwhoputthepatientonthewaitinglistshouldbetheteamwhoperformtheoperation.
‘ChooseandBook’createsinefficiencywhenprimarycarereferstothewrongspecialist.Surgeonswithinaunitarenotallowedtorefertoeachother,meaningtheymustsendthepatientbacktotheGP,whowillhavetofindanotherslotwiththecorrectsurgeon.Allowingsurgeonstorefertoeachother,aswellasseniorinputatthefrontendofreferral(andalsogreatercontinuityofcare)wouldallhelpwiththisproblem.
Procedures of limited benefit
Thereare,foranumberofreasons,unnecessarysurgicalinterventions,oratleastinterventionsoflimitedbenefit,thatarecurrentlydone.
Triageisoneareathatgeneratesunnecessarycosts(forexample,scans)whenconductedbyinadequatelytrainedandsupportedstaff.
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Clinical responses to the downturn 032
MRIuseisasignificantexampleofoveruse:
Alocalinvestigationbyoneofthegroup•showed80percentofusewasunnecessaryandjustcreatedunnecessaryonwardreferral.
AccesstoMRIcouldberestrictedto•consultant-level.Atpresentitisgrosslyoverusedthroughbeingabletoberequestedbymanydifferentpractitioners(forexample,physiotherapists)andatlowlevelsofseniority.
Alternatively,accesstoMRIcouldberestricted•sothatthoserequestingit:
havebeenproperlytrainedtointerpret–theresults
areabletospeaktothepersonwhowrites–thereport(whoisoftenbasedoverseasatpresent).
OveruseofMRIisalsoencouragedbystrategichealthauthoritiespurchasinggenerousbulkcontractsfromcommercialcompanies.Thisincentivisesoverusetouseupthefullquota.
In-theatre efficiency
Therearesignificantgainsstilltobemadeintheefficiencywithwhichtheatresarerun,althoughtheextenttowhichorthopaedicsonitsowncanmakeacontributiontothisislimited.
Theanaesthetist,surgeonandtheirteamsneedtobeavailableandpresentwellinadvanceofthescheduledliststart-timetoensurefulluseoftheavailableresources.
Considerationcouldbegiventoall-daytheatrelists,whichwouldhelpeasethelog-jamthatcurrentlybuildsuptowardstheendofeach
day. Alternatively,morefocuscouldbeplacedonusingtheexistingfivedaysmoreeffectivelybeforeallowingtheatretimetoamorphouslyexpand.
Implants
Thecurrentsystem,whereeachindividualhospitalpurchasesitsownimplants,issub-optimal.
Thereareoftenover100variantsforaparticularimplant,forexamplehipreplacements,whenin90percentofcasessurgeonscoulduseonlythosefewrecommendedinNICEguidelines.
Thefollowingcaveatsshouldbeaddedtothis:
roomforinnovationmustbeallowed•
wherethereisaparticularreasonwhya•surgeonwishestodosomethingdifferently,theyshoulddiscussitwithandseektheapprovaloftheirpeers.
Useofimplantsintraumaneedstoberationalisedinasimilarwaytothatofjoints,i.e.aregistry.
TheremaybescopeforincreaseduseofplasterofParisratherthanimplantsasthecostislowbutqualityofcarecanbejustashigh.However,thiswouldrequirerediscoveryofsomeoftheskillsneeded.
Cancellations
Someofthecurrentbestpracticeinmanagingcancellationsneedstobereplicatedmorewidely.Forexample,meetingwiththe
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Clinical responses to the downturn 033
wholeunitteamonaweeklybasistolookatcancellationsthatoccurredandassesshowtheymighthavebeenavoided.
Oneofthemajorcausesofcancellationsisalackofcapacity.
System-wide issues
Consultantsarecurrentlypaidextraforextrawork(forexample,clinicsandoperatinglists)andarethereforeincentivisedtotakelesstimedoingbasicpatientworkandwardrounds.Thispushesthesetasksontoseniorhouseofficers(whohavelesscontinuityofcarewiththepatient)andresultsintestsbeingrepeatedwithnoonereallymanagingthepatient’scare.
Ontheissueoftheatreefficiency,worktobringanaesthetistsmorecloselyintoateamworking
culturewouldbeeffective.
Thethresholdsthatjuniordoctorsmustreachbeforebeingpromotedaregettinglower,meaningthecompetenciesofcareergradeorthopaedicsurgeonsarelowerthantheyusedtobeandahigherproportionoftheserviceisbeingdeliveredbynon-consultants.Apropercareerpathwayforpre-consultant-leveldoctorsisneeded.
Medicalschooltraininginorthopaedics/trauma,oftenaslittleastwoweeks,isinsufficientgiventhepervasivenessoftheseconditionsatalllevelsoftheNHS.
TheEuropeanWorkingTimeDirectiveneedstoberecognisedasacauseofmuchunnecessarycost.Agencybillshaverisensignificantlyasaresult.Manytrustsarefindingitdifficulttoemploystafftofilltheirrotas.
Workshop participants
Mr Mike Bell, Immediate Past President, BOA (Sheffield)
Mr Steve Bollen (Bradford)
Mr Dave Clark (Derby)
Mr Tony Hui, Immediate Past President, BODS (Middlesborough)
Mr Peter Kay, President, BOA (Wrightington)
Mr Mike Kimmons, Chief Executive Officer, BOA
Mr John Marshall (Devon)
Miss Clare Marx, Past President 2008/09, BOA (Ipswich)
Mr Sudhir Rao (South London)
Mr Jeremy Ridge (Dewsbury, Mid Yorkshire)
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Clinical responses to the downturn 034
NeonatologyThe following recommendations emerged from the British Association of Perinatal Medicine’s group regarding areas that could be explored in terms of improved efficiency in their specialty.
Dischargeplanning:
thereisaneedforqualitydischargeplanning•tobecomestandardpractice.Thisdoesnotimplysendingpeoplehomeearliertomeetatargetorreducecosts,butworkingwithparentsfromthepointofadmissiontoplandischarge
mythsandoutdatedrulesaroundonly•dischargingbabiesaboveacertainweightorcertainagestillperpetuateinneonatalunitsaroundthecountry
improvingthedischargeprocesscouldleadto•fasterreleaseandfewerbeddays.
Tests–thereisscopeforstandardisingtheuseofcertaininvestigationssuchasMRI.
Follow-upprocedures–atpresentthereisgreatvariationinthecriteriaforfollow-upafteranadmissiontotheneonatalunit.
Feedingpractices:
anationalapproachtototalparenteral•nutrition(TPN)shouldremovevariationinpractice,improvequalityofcareandreducerisks
thereisgreatvariationintheintroduction•andmanagementofeneteralfeeding.ImprovedguidanceagreedamongstnetworkshasthepotentialtoreducetheneedforTPN
thereisagreatdealofvariationin•breastfeedingsupport.Greateravailabilityofmothers’breastmilkcouldsimilarlyreducetheneedforTPN.
Themes
Reduce non-rational variation in practice•
Stronger networks•
Demand management•
‘24 weeks and below’ position•
Use of SHOs/junior doctors•
Systemic issues•
Reduce non-rational variation in practice
Currently,thereiswidespreadvariationinpracticethatdrivesincreasedcostwithoutevidentialsupport.Thisaffectsnotjustthetypesoftestsdone,butbasicpracticearoundwhentoadmitandwhentodischarge.
Theareastoaddressarelistedbelow.
Inappropriateadmissions,suchas:
highratesofbabiesadmittedtoneonatal•unitswithoutrequiringanymedicalintervention–ratesarereportedtorangebetween9percentand37percentofnormalbirths.Thisvariationdoesnotseemtobelinkedtoanyparticularfactorandprobablyrepresentsestablishedpractice
routineadmissionofbabieswhosemothers•havediabetes
inappropriateuseofspecialcare.•
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Clinical responses to the downturn 035
Drugs:
harmonisepracticeregardingthedurationof•antibioticsuseandthetimeneededtogetnegativecultures(inordertoallowantibioticstostop)
clearerguidanceregardingtheuseof•Palivizumab
FetalFibronectinisrecommendedin•numerousdocuments,yetisnotuniversallyused.Ithasthepotentialtoreducethenumberofwomentransferredunnecessarily(becauseofaperceivedriskofpre-termdelivery)
NICEguidanceonantenatalsteroiduse•amongstnear-termbabiesisrequired.
Otheraspectsofvariablepractice:
transfusion–everynetworkshouldagreea•protocolfortheuseofbloodproducts
infectioncontrolproceduresarestillsub-•standardinmanyunits,especiallyinrelationtothecareoflonglines
equipment–single-useitemsareabigarea•ofwastage,particularlyforhighvolumeprocedures
training–newbornlifesupport(NLS)or•equivalenttrainingcostscouldbereducedbyusingadifferentsupplier.Thereisalsopotentialforthecourseitselftobesimplifiedformanystaff.
Howmuchofthisvariationshouldbereducedwasdiscussed.Theimportanceofbenchmarkingpracticeandusingthesedatatochallengeoutlierswashighlighted.Cliniciansvaryingfromthenormshouldbemadeawarethatitwastheirprerogativetoexplainwhytheydifferedfromtheirpeers.However,itwasnotfelttobeappropriatethatindividualscould
dowhattheylikeduntilitwasproventobeineffective.
Itwasnotfeltthatpatientswouldbeconcernedaboutthedegreeofclinicianautonomythatcouldbelostthroughthesemeasures.Itwasmoreconcerningtothemthattheycouldbegivenacompletelydifferentcourseoftreatmentdependingonwhichunittheywenttoorwhichdoctortheysaw.
Stronger networks
Strongernetworksinneonatologywerefelttohavegreatpotentialforthebetteruseofresources.Examplesaregiveninsomeoftherecommendationstoreducevariation(seeabove).
StrongernetworkdeliveryofneonatologywassupportedinthemostrecentNationalAuditOfficereportonneonatology.
Inadditiontotheexamplesabove,theycouldcreatemuchmoreefficientmovementofpatients,betterbeduse,fasterreleaseand,perhapseventually,fewersitesinwhichneonatologywasdelivered(althoughitwasrecognisedthatthislastpointreliesonseveralotherfactors).
Demand management
Thereisalimitedextenttowhichtheremitofneonatologyallowsitspractitionerstohaveanimpactonthedemandthatexistsfortheirservices.
Onemajorareawheretheycanmakeadifferenceisunnecessaryreferral(seevariationsectionabove–Fibronectin).
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Clinical responses to the downturn 036
Ofpatientswhodoneedneonatalcare,itwassuggestedthattakingagreaterinterestinthelinksbetweenat-risk(forexample,drug-dependent)mothersafterthebirthofachildandfamilyplanningservicescouldreducefuturepre-term/unsafebirths(andhencedemand).Whilethebabyistechnicallythepatient,andhencetheneonatologist’sprimaryconcern,neonatalservicescommonlyofferotherresourcesandinformationthattheyfeeltheparentneeds,andhencethegroupfeltthatbetterlinkswithfamilyplanningwouldnotrepresentanyconflict.Thiscouldbebuiltintothedischargeprocess.
‘24 weeks and below’ position
Itisimportanttorecognisethedebateonwhethertreatmentshouldberefusedtoveryimmaturebabiessuchasthoseunder24weeksofgestation.However,thissituationhasbeenclearlysetoutintheBritishAssociationofPerinatalMedicine’sandtheNuffieldTrust’spositionstatementsonthistopic.
Itwasthoughttobeworthre-emphasisingthatabroadclinicalconsensusdoesexist,albeititisnotwidelyunderstoodbythepublic.
Under24weeks’carewasnotthoughttobeasignificantcostissueforthespecialtyasthenumberofpatientsissmall.Notmentioningthisissueaspartofthediscussionswouldinviteittobehighlightedasanomission.Itisanimportantissue,butnotanimportantcostissue.
Use of SHOs/junior doctors
ThecurrentmodelofSHOuseissub-optimal.ABritishAssociationofPerinatalMedicinestatementonstaffingmodelsispartofthe
BritishAssociationofPerinatalMedicine2010standardsdocument.
Manybasiccompetenciesamongjuniordoctorsareunsatisfactory.Theyshouldnotbeallowedtoprogressintheirtrainingiftheycannotdemonstrateacertainlevelofcapability.Thiswouldhaveanimpactonpatientsafetyandwaste.
Other system-wide issues
Themovetomoretransitionalcareandbetterhomecarepackagesisbeingblockedbysometrustsastheproperincentivestomovecareoutofhospitalsdonotexist.
Thereshouldbeanationalprocesstojudgewhethercertaininterventionsaretrulyeffective.Whereevidencedoesnotexist,‘borderlineinterventions’shouldbeintroducedinawaythatallowsproperassessmentbeforewidespreaddissemination.Thiswouldsupportneonatologytoimplementsomeoftheaboverecommendationsonvariationbyprovidingagreaterevidencebaseonlow-valueinterventions.
ThereisariskthatifPCTscutthequantityofIVFavailable,morepeoplewillgoabroadfortreatment,wherethestandardnumberofeggsimplantedishigher.ThiscouldleadtomoremultiplebirthsbackintheUK,requiringmoreexpensiveneonatalcare.
Publiceducationoftherisksofhavingchildrenprematurelyshouldbebetter.Ifnothingisdonetocombatrisingexpectations,thedemandforneonatologywillcontinuetoincrease.
Therearefewsystemicleverstodrive
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Clinical responses to the downturn 037
Workshop participants
Dr Eleri Adams, Oxford Radcliffe Hospitals, consultant neonatologist
Dr Pam Cairns, University Hospital Bristol, consultant neonatologist
Mr Andy Cole, Chief Executive of BLISS
Prof David Field, President of BAPM
Dr Simon Struthers, Winchester and Eastleigh, consultant paediatrician
Dr Merran Thomson, Queen Charlottes and Imperial, consultant neonatologist
Dr Miles Wagstaff, Gloucestershire, consultant paediatrician
standardisation.PCTsarenotabletotakethisroleastheylacksufficientdetailedknowledgeofthespecialty.
TheNHSPassport,ifitcomesabout,willbeasignificantassetinmakingbetteruseof
neonatalstaffbymakingthemfreertomovearoundanetwork.
Thehighlydistributedwaythatneonatologyiscurrentlyorganisedcouldberationalised,althoughthiswouldofcoursereducechoice.
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Clinical responses to the downturn 038
DermatologyThe following recommendations were produced by the British Association of Dermatologists to highlight where resources could be released in NHS dermatology services, while maintaining or enhancing quality.
Patientsshouldseetherightperson,intherightplace,firsttime,toobtainadefinitivediagnosisandensurethattheyaresubsequentlyseenbythemostcost-effectivememberoftheteaminprimaryorsecondarycare,appropriatetotheirdiagnosis.Thisismostefficientlyachievedbyconsultanttriageofreferralletters.Forthemostcommondiagnosesthiswillusuallymeanthepatientinitiallyseeingaconsultantdermatologistorbyaservicewhichhastimelyaccesstoaconsultantifneeded(i.e.anintegratedservice).
TosupportthetransitionfromPCTtoGPcommissioningtheBritishAssociationofDermatologists(BAD)willfacilitatetheproductionofevidence-basedguidelinesforcommissionersonmeasurementofqualityandoutcomeforskindiseaseinterventionsindicativeofahigh-qualityservice.Thiswillinvolveamulti-stakeholdergroupincludingpatients,nurses,GPs,dermatologistsandotherhealthcareprofessionalsinvolvedinthecareofskindisease.Aworkinggroupisalreadyintheprocessofdevelopingtheseminimumdataset(MDS)standardsnow,bothacrossdermatologyandbysub-specialty.
TheBADconsidersthattheseMDSstandardswillbeparticularlyusefulinanenvironmentof‘anywillingprovider’byhelpingcommissionersfindtherightbalancebetweencostandqualityofservicesandensuringpatientsgetthesamequalityofcarewhereverandbywhoeveritisprovided.
Demand management
1. Follow-up protocolsThereisagreatdealofvariationinfollow-uppractices,withmanypatientsattendingforfollow-upappointmentslongaftertheseaddvaluetothepatient.
Themes
Commissioning services for people with •skin conditions
Demand management•
Technology to triage referrals•
Reducing non-attenders•
Telephone consultations and non •face-to-face consultations
Generic substitution for prescribing•
Reducing unnecessary consultations•
Other varied initiatives•
Other system-wide issues.•
Commissioning services for people with skin conditions
EvidencetodatefromCareClosertoHome1andworld-classcommissioning2suggeststhatqualityservicesshouldbeintegrated.Toobtainbestuseofresources,allstakeholdergroups(commissioners,dermatologists,GPsandpatientgroups)shouldbeinvolvedinservicedesigntominimise‘blindalleys’andmaximiseefficientpathways.ConsultantsarethegreatestexpertresourceintheNHSandprocessesexcludingthemwillinevitablybeflawed,particularlyasundergraduateandGPregistrartrainingcontainminimaldermatology.
Forthe6percentofskindiseasewhichrequirespecialistassessment,evidencesuggeststhatthisismostefficientlyandeffectivelydeliveredbyamulti-disciplinaryteamledbyconsultantdermatologistswhocanbestprovideanaccuratediagnosisandbestmanageskincanceretccost-effectively.
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Clinical responses to the downturn 039
Patientsshouldbefollowedupifthereisaclearindicationsuchas:structuredfollow-upforskincancer;thosepartofsharedcareprotocols;thoseimmunosuppressedpatientsbeingmonitoredforcancer;patientswithunstabledermatosesrequiringmodificationoftreatment;andthosewithunstablesolardamagethatrequireongoingtreatment.Forothers,ifnochangeinmanagementisrecommended,theyshouldbedischargedwithanappropriatemanagementplanwhichisagreedbythedoctorandpatient.Thisprocesswouldbefacilitatedforpatientswithchronicdiseasesiftheyfeltreassuredthattheywouldbereferredbackquicklyandeasilyiftheirsituationchanged,somethingwhichisbecomingmoredifficultinthecurrenteconomicclimate.
Patientsshouldhaverapidaccesstoappropriatediagnosticskillsasandwhenneeded.Ifthisprocesswaseasierthenitmayfacilitatethedelegationofmorefollow-uptomembersofthedermatologyteam.
Itshouldbeappreciated,however,thatfollow-upofthepatienttoseeifatreatmentplanhasworked,orreviewingasurgicalpatienttogainfeedbackonthesurgicaloutcome,arelearningeventsthatwillimprovefuturecare.Thelossoftheseencounters,whilstpossiblyreducingcostintheshortterm,reducesthelearningaspectsofpatientcare.
2. Procedures of low clinical priorityThecriteriaforlowpriorityproceduresarenotuniformlyappliedacrosstheNHS,andthereissomeunnecessaryvariationbetweensub-specialties.
IftheNHSwascleareraboutwhatitdoesanddoesnottreat,itcouldtakeadifferentapproachtotheseproceduresby,insteadofbanningthem,tellingpatientsthattheycanpaytohavethemdone.Thiswouldcreateasourceofrevenueforthehealthserviceand,sincemanycaseswouldinvolveminorsurgicalprocedures,wouldprovide
educationforjuniordoctorsandsomenurses.
Skintagsandseborrhoeickeratoseswouldbepossibleexamplesofareaswherethiscouldbedone.
3. Reducing unnecessary procedures in primary careProceduresof‘limitedclinicaleffectiveness’(POLCE)whicharenottobereferredtosecondarycare,unlessthereisdiagnosticuncertainty,shouldalsonotbetreatedinprimarycare.
Onequalitycontrolwhichcouldbeappliedlocally,wouldbecost-effectiveandthatdermatologistsshouldsupportisbiopsyofundiagnosedrashesandlesionsorremovaloflesions.Thisshouldnotbedoneunlessanduntilexpertopinionhasfirstbeengiven.
ThevalueofinsertingthedermatologistintothepatientpathwaybetweentheGPanddermatologysurgeryhasalsobeendemonstratedinsomeareas.Two-weekcancerclinicsreassureanddischarge80percentofpatientsandtherebysavesurgerycosts.Fortypercentofdermatologypatientsarereferredwith‘lesions’andmostofthesearereassuredanddischarged,therebysavingsurgerycosts.
Technology to triage referrals
1. Two-week cancer referral triageOnedermatologyunitreportedthattheyhadmanagedtomakesignificantproductivitygainsfromtheapplicationofteledermatologytotheirtriageprocess.Anotherunitusesapooloftrainednursesincommunityhospitalstomakeaninitialconsultationandtakepatienthistoriesanddigitalimagesoftheaffectedareasofskin.Thesearesenttothedermatologistelectronicallyfortriage.Thishasresultedinasignificant
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reductioninthenumberofnewpatientsthedermatologistneedstoseefacetofaceandhas,therefore,improveddepartmentalefficiencyandsomewaitingtimes.Patients,however,stillneedtotraveltothe‘communityhospital’anditisnotclearwhetherornottheresourcesneededforthelongernurseconsultationandphotography,combinedwiththeduplicateconsultationandtravelforthoseultimatelyseeingadoctor,resultsinasignificantsaving.
Suchmodelsarecurrentlystillcontroversialandthereisnoagreementintheprofessionaboutpatientsafety.Mostunitsdostillseeallsuchpatientssotriaged.
2. Triage of ‘rashes’Whenusedfor‘rashes’,teledermatologymayhelptriagebutonlyifhigh-qualityimagesarecombinedwithagoodhistory.Thismayallowupto20percentofreferralstoberedirectedtotheGP3butshouldonlybedoneaspartofanestablishedandintegratedserviceandshouldbecloselyauditedforcostandsafety.Thequalityandcost-effectivenessofoutsourcingeithertheimagingortriageshouldbeconsideredhighlyquestionable.
Reducing non-attenders
Consultationswherepatientsdonotattend(DNA)areaclearareaofwastedcapacity.
Simpleautomatedsystemsthattextand/oremailpatientswithremindersoftheirappointmentsignificantlyimprove,i.e.reduce,DNArates.InsomeareastheyresultedinDNArateshalving,withasavingofresourcewhichcanbereinvested.FewerDNAswillpermitanecessaryreductioninclinictemplates,whichcurrentlyallowfor‘noshows’.Theincreaseinthroughputwouldthenbemoderate.
Thecostofthesesystemsisnowsmallandthere
arevariousotherfunctionstheycanprovide,suchasusingthepatient’sfirstlanguageorremindingthemofparticulardocumentstheyneedtobringwiththemtoanappointment.
Telephone consultations and non- face-to-face consultations
Forpatientfollow-up,manyoftheface-to-faceconsultationsundertakenbydermatologistscouldbedoneasaconversationoverthetelephoneinstead,increasingproductivityandreducingpatienttransportcosts.Insomecases,suchaschronicdiseasemanagement,these‘follow-ups’couldbeconductedbyanurseinsteadofthedermatologist.
Someofthemostcommonconditionscouldbefollowedupthisway,suchaspatientswithchronicdiseases,thoseonsystemicdrugsetc.ThelatteristhesubjectofaQOF‘sharedcare’proposalwhichwouldreducesecondarycarefollow-upandimprovesafetyforthisgroupofpatientswhoareindangerofbeinglostduetonewpatienttargets.
CostsavingswouldaccruetothewiderNHSratherthanthetrustinwhichthedermatologistworks,sincethetarifffortelephoneconsultationsisconsiderablylessthanthatofaface-to-faceone.
Generic substitution for prescribing
Forcertaincommonsystemicdrugsthereisscopetoincreasetheuseofgenericsubstituteswithoutaffectingquality.ExamplesincludeIsotretinoinandciclosporin(aslongaspatientsreceivethesame‘brand’throughouttheirtreatmentcourseasbioavailabilitymaydifferbetweenproducts).
Electronicprescribinginsecondarycare(as
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existsinprimarycare)hasthepotentialtoreducecostsbyrestrictingprescriberstogenericagents,reducingtherisksofprescribingdrugswhichinteractandlimitingprescriptionstoagreedduration,allofwhichimprovesafetyandsavemoney.
ThelistofDermatologySpecials(www.bad.org.uk//site/1284/default.aspx)listsapprovedspecialformulationswhicharecommonlyusedbydermatologistsintheUK.Arrangementshavebeenmadeforthesetobeproducedcentrallyatlowcostandhighquality.Communitypharmacistsshouldbemandatedtopurchasetheseproductsfromthesecentresandnotfromsmallvolumeproducerswherecostsareinvariablyhigh.
Reducing unnecessary consultations
1. Modifying the pregnancy prevention planThepregnancypreventionplanstatesthatfemalepatientsoncertaincommondrugsprescribedbydermatologists(Isotretinoinandalitretinoin)mustbeontwoformsofcontraceptionandarerequiredtoattendthehospitalonceamonthforapregnancytest.
Theplanhasnotreducedtheincidenceofunplannedpregnancies,however,andtherationaleforitscontinuationisquestionable.
SharedcarewithGPswithSpecialInterestsinthecommunitymaybeeffectiveaslongastheyarecognisantofthesafetyissuesandareaccreditedbythedermatologistsunderwhosenamethedrugisprescribed,asdictatedbyMHRAguidance.
2. WigsDermatologistsarecurrentlytheonlyhealthpractitioners(otherthanoncologists)permittedtoprescribewigs.Thereisnoclinicaljustificationforthisrule,whichcreatesneedless
demandsondermatologyunitsandgeneratesunnecessarypatientvisitsfortheprescribingandrenewalofwigs.
TheabilitytoprescribewigsshouldbewidenedtoattheveryleasttoGPs.
Other varied initiatives
1. Management of cellulitisCellulitisisresponsibleforover£100milliononpatientcarenationallyintheNHS.Auditshowsapproximately30percentofpatientsdiagnosedwithcellulitisbyGPsandgeneralphysiciansinfacthaveotherdermatologicalcausesofredlegsanddonothavecellulitis.Consequently,admissionofthesepatientstohospitalforoneormoreweeksforintravenousantibioticsresultsinwastedbedstays,inappropriateadmission,inappropriateIVantibioticsresultinginCDifficileinfectionanddelayeddischarge.
Furthermore,muchcellulitisisduetounderlyingskindiseaseandthereforecellulitisisoftenrecurrentiftheskindiseaseremainsunrecognisedanduntreated.Lowerlimbcellulitiscan,ifcorrectlydiagnosedandmanaged,almostalwaysbetreatedathome.
Aninnovative,dermatology-ledlowerlimbcellulitisserviceintheNorfolkandNorwichUniversityhospitalhasoverthreeyearsalmosteliminatedinpatienttreatmentoflowerlimbcellulitisanderadicatedinappropriatetreatmentwithIVantibiotics.Patientsaremanagedathomewithhospitalvisitstomonitorclearanceandaimtopreventrecurrence.
2. Joint working with GPs to reduce demandManyGPscallorwriteletterstodermatologistsaskingforadvice.Thiscurrentlyisn’trecognisedasactivityandso
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Clinical responses to the downturn 042
isn’tchargeable.Introducingatariffforthiswouldremoveperverseincentives,improvecommunicationbetweencliniciansand,studiesshow,reducereferral.
PaymentbyResultsrequirestheretobeapatientencounterforchargingtooccur.Forletter/emailortelephoneadvicetobechargeablethiswouldhavetochange,buttheBADwouldsupportthis.
3. Teaching and trainingTrainingandeducationshouldbeanintegralpartofanyproposedserviceifitistobeofhighqualityandsustainable.
GPeducationshouldbetargetedtothecommondermatoses.Whiletherearethousandsofskinconditionsthatdermatologistsneedtobeawareof,90percentofGPreferralsrelatetoless than 20 conditions. Some of these cases donotneedreferralorcanbemanagedinprimarycareoncethediagnosisisconfirmedandatreatmentplanagreed.Ifeachhealtheconomytargetedthediagnosisandmanagementofskinlesionsbyfundingface-to-facetuitionorviaexistingonlineeducationpackages,inappropriatedemandonspecialistresourcescouldbesignificantlyreduced.Dermatologistswouldsupportthis,butthechangesneededtomanageandresourcethisinitiativewouldrequireinvestment.
Other system-wide issues
Thecommissioningofanywillingproviderdoesnotresultincost-effectivehealthcare.Profitmakingproviderscancherrypickthoseaspectsofcarewhichareprofitablebutrarelytakeonthemorechallengingonesandexpensiveones.ThisleavesNHSorganisationswiththemoreexpensiveareas,forwhichtheystillrequiremostofthecostbasetheydidbefore.Commissioningshouldconsidertheentiredermatologyservicebasedonrobustneedsassessmentsandincludeallrelevantstakeholders.
Tariffmaysometimesencourageunnecessaryattendancesbyprovidinganincentivetogivingapatientafollow-upappointmentforadaycaseprocedureratherthanoperatingonaseeandtreatbasis.
References
www.bad.org.uk/Portals/_Bad/Official%201.Responses/Service%20models%20fig%20and%20evidence.pdf
NHSPrimaryCareContracting(2008).2.Providing care for patients with skin conditions: guidance and resources for commissioners.Leeds:NHSPrimaryCareContracting
SchofieldJK,GrindlayD,WilliamsHC.(2009).3.Skin conditions in the UK: a health care needs assessment.CentreforEvidenceBasedDermatology,UniversityofNottinghamUK
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Workshop participants
Officers
Dr Tanya Bleiker, Editor, Derby
Dr David Eedy, Treasurer, N Ireland
Dr Mark Goodfield, past President, Leeds
Dr Catriona Irvine, Clinical VP, Canterbury
Dr Stephen Jones, President, Wirral
Dr Nick Levell, Hon Sec, Norwich
Dr Jane Sterling, Academic VP, Cambridge
Clinical Services Committee
Dr Robert Burd, Leicester
Dr Sheru George, Amersham
Dr Karen Gibbon, London
Other members
Dr Robert Chalmers, Manchester
Dr Ed Seaton, London
Dr Graham Sharpe, Liverpool
Additional comments received from
Dr D Mallett, Peterborough
Dr J Schofield, Lincoln and West Hertfordshire
41
This joint publication brings together practical recommendations from focus groups with seven specialty medical societies and Royal Colleges, each of which were asked to suggest ways that clinicians in their own specialties can release NHS resources while maintaining or enhancing quality. Chapters include orthopaedics, neurosurgery,
dermatology, neonatology, pathology, vascular surgery and geriatrics. The recommendations will be of use to local commissioners and providers, clinical leaders, policy makers and anyone else seeking to address the most serious period of financial constraint in the history of the NHS.
Clinical responses to the downturn
The NHS Confederation29 Bressenden Place London SW1E 5DDTel 020 7074 3200 Fax 0844 774 4319Email [email protected]
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