SUBJECT: WAITING TIMES

Meeting of Lanarkshire NHS Board 24 November 2010 Lanarkshire NHS Board 14 Beckford Street Hamilton ML3 0TA Telephone 01698 281313 Fax 01698 423134 www.nhslanarkshire.co.uk SUBJECT: WAITING TIMES 1. PURPOSE The purpose of the paper is to advise the NHS Lanarkshire Board of progress against delivery of waiting time and performance guarantees as set out in the Local Delivery Plan (LDP) for 2010/11. 2. CONTENT/SUMMARY OF KEY ISSUES There are no patients waiting over twelve weeks for an outpatient appointment and nine weeks for an inpatient/day case appointment in NHSL at 31 October 2010. There is however significant pressures on selected specialties (outpatients) including gastroenterology, neurology and cardiology. Analyses of the trends for these specialties would suggest some increase in demand, particularly in gastroenterology and neurology. There is, however, underlying theme of variation in clinical practise. This particularly applies to use of clinic capacity; vetting practises and volume of return patients who require long term condition management. A similar pressure exists with inpatients/day cases in general surgery. This is attributed partly to demand increasing but also effective use of available theatre time and capacity. Both of these areas are under review and plans are being developed to put corrective action in place. No patient is waiting over four weeks for the eight key diagnostic tests although the impact of bowel screening continues to exert pressure on the service. In addition, there is continued compliance against cancer guarantees. Performance against the four hour maximum wait at Accident and Emergency is below the guarantee level. This reflects particular pressures at Hairmyres Hospital. In October performance at Hairmyres was 94.15% against 95.47% at Monklands and 97.84% at Wishaw General with an overall performance of 95.89% against the target of 98%. The breech analysis at Hairmyres indicates that most delays can be attributed to waiting for first assessment and waiting for a bed. The priority at Hairmyres is to agree the immediate actions that need to be taken based on analysis of factual information on activity and trends. This is not confined to activity in Accident and Emergency but extends across the whole patient journey including patient discharge. A short life working group has been established, chaired by the Director of Acute Services, with clinical representation from the site and managerial 1

representation for both acute and primary care. The remit of the group is to identify and analyse activity and trends and to agree the short term actions required to improve patient flow, patient experience and performance. Initial analyses of site performance would suggest that there are a large number of beds on the site blocked with patients who have been in hospital for more than 50 days. Monklands performance is largely driven by major gaps in the staffing rota which are leading to delays with patients waiting for first assessment and treatment. As previously reported, Implementation of Modernising Medical Careers (MMC) continues to impact on service delivery. The continued inability to effectively staff middle grade rotas continues to place increased pressure on consultant staff to provide that cover. This has a subsequent impact on the elective programme that has resulted in cancelled or displaced activity. This is causing inconvenience to patients and the need to identify alternative capacity either internally or externally. This is now resulting in increased costs to replace lost capacity with subsequent pressures on budgets As we move into the winter period it is critical also that there is sufficient senior cover at ward level. The ability to effectively discharge patients will be critical to the smooth flow of patients through the system. This may further impact on the elective programme and alternatives are currently being explored. The bowel cancer screening programme continues to impact on endoscopy. The upward trend in number of tests to be carried out continues to place increased demand on staff and services. NHSL continues to deliver the maximum waiting time guarantee of four weeks although this has only been achieved through increased clinic lists at additional cost to the NHS Board. A review of the Endoscopy service is nearing completion. There is full clinical engagement in the work and evidence is beginning to emerge that will inform future decision making. The outcome will be reported to the NHS Board. This work is being taken forward as part of the Lean programme designed to improve a range of specialties. Progress continues to be made to improve performance measures as set out in the LDP. Variations have been highlighted by specialty, site and individual clinician and actions are being taken to address those. A key priority is to ensure that available capacity is used in full and that throughput and productivity achieves agreed levels and that where possible and appropriate clinic and theatre capacity are backfilled. The requirement is to deliver improvement against targets by March 2011. It is anticipated that the review of administrative and clerical staff will support that process with inclusion of proposals to improve patient scheduling by reducing the number of staff involved in the process. An enhancement of planning and performance will also offer potential to improve monitoring and review, prompt pro active measures to address service pressures and look retrospectively at trends to inform decision making and future action. Considerable importance is attached to developing patient flows from referral to discharge by specialty and sub specialty with time measures attached that could be flexed at different stages of the patient journey. That continues to 2

represent work in progress. Whilst this work is essential to developing the NHSL response to delivery of 18 Weeks RTT, it is acknowledged that the ability of the NHS Board to move beyond delivery of stage of treatment guarantees is constrained by the financial situation locally and nationally. At this stage the priority is to sustain stage of treatment targets. There continues to be dialogue between the NHS Board and the Access Support Team on 18 weeks RTT. The timeline for delivery of 18 weeks RTT remains at 31 December 2011. In contrast to stage of treatment target, there is expected to be a percentage tolerance applied to the target to take regard of complex patient pathways and variances in capacity. The extent of that tolerance has not yet been determined. It is however anticipated that this will be 90% of admitted and non admitted pathways. Performance in October against that combined target is 73.8%. There are currently two types of pathway (admitted and non admitted) being measured by the Scottish Government. Pathway measurement is constrained by the ability to definitively link the patient journey and capture clock stops at the end of a pathway in outpatient settings. In order to evidence progress towards achievement of the 18 weeks pathway two main measures are being applied. Completeness examines whether the clock start and clock stop of a pathway is measured and Performance examines how many pathways are completed within 18 weeks. Service modelling work is underway that will inform the service and cost implications of delivering the target. At this stage there is no commitment to move beyond the modelling phase. At the end of October 2010 the position was: Admitted Pathways Non-Admitted Pathways Completeness Target October Performance Target October 72.2% 75% 47.9% 70% 72.3% 72% 79.1% 60% 3. DELAYED DISCHARGES/ADULTS WITH INCAPACITY (AWI) There have been 8 delayed discharges out with guarantee at the monthly census date on 15 October 2010. Whilst delivery of the guarantee is achieved at census review. This places considerable pressure on inpatient beds. This is compounded by a high number of Adults with Incapacity (AWI) who whilst not included in the formal monthly census contribute to bed pressures and blockages. In September 2010 an expert group was established nationally with representation from health and social care. In parallel, it has recently been announced that there will be the establishment of a Pooled budget for Reshaping Older People s Services. It is considered that work on the delayed 3

discharge agenda needs to feature highly within discussion on how this pooled budget with be administered. The expert group will continue to meet and make recommendations by February 2011. A questionnaire has been issued by the group for completion to NHS Boards and Local Authorities to inform their work. In October 2010, the NHS Board received details of the winter plan. This was informed by guidance issued by the Scottish Government. A multi agency approach is being adopted and work continues to ensure a robust plan for implementation in December 2010. Each acute hospital will have a site plan informed through discussion with clinicians from Primary and Secondary Care and colleagues in Local Authorities and the Scottish Ambulance Service (SAS). Discussions are continuing at Director level between NHSL and North and South Lanarkshire Councils to consider delayed discharges and the impact on services over the winter period in the context of a challenging financial situation. 4. ACTIONS/NEXT STEPS NHS Lanarkshire will sustain the stage of treatment waiting time guarantees to 31 March 2011. Progress will be made against the performance improvement guarantees and those will be evidenced through the period to 31 March 2011. The group chaired by the Director of Acute Services will implement the actions agreed to better understand and respond to the issues identified designed to improve patient flow and performance. Discussions will continue with North and South Lanarkshire Councils to agree specific actions to minimise the impact on service delivery of increased pressures and financial constraints. In addition, joint action will be taken on the measures emerging from Scottish Government on pooled budgets for older people and measures to counter the pressure generated from delayed discharges. As previously agreed, the waiting times glossary of terms is attached for information. 5. CONCLUSIONS The Board is asked to note the waiting time and performance guarantees on which NHS Lanarkshire is measured in 2010/11 at 31 October 2010. Further details on the content of the paper are available from Rosemary Lyness, Director of Acute Services on 01698 245003. Rosemary Lyness Director of Acute Services 4

November 2010 Waiting Times Glossary Term Description 18 weeks Also known as Referral to Treatment (RTT). This is the waiting time standard for a patient s whole journey, from initial referral for a condition, to treatment. Will be introduced in December 2011. Admitted A RTT pathway where the waiting period stops when a patient pathway receives treatment or a medical device is fitted in an inpatient or day case setting. Clock Start For RTT this is the date a referral is received by a Consultant led service from an agreed source for service requests. Clock Stop The point where a RTT pathway waiting time calculation ends as a result of treatment or other care activity. Consultant Led A Consultant-led team is a clinical service where a Consultant retains Team overall clinical responsibility for the service, treatment or health care team. Includes Secondary Care services provided in community settings and GPs with Special Interests. Could Not Occurs where a patient has accepted an offer of appointment or Attend (CNA) admission but then cancels the date in advance. At this point the waiting time clock for that appointment or admission is reset to zero. A patient may cancel 3 times before a decision is made to return to care of original referrer. Did Not Attend Occurs where a patient has accepted an offer of appointment or (DNA) admission but then fails to attend on the date. Depending on the circumstances and policy a patient may either be returned to original referrer or the waiting time clock is reset to zero and another reasonable offer is made. Direct Access A referral to direct to diagnostic services where there is no Diagnostics transfer of clinical responsibility. The referral does not start a RTT pathway. ereferral The process of electronically submitting a referral request from General Practitioner IT systems to Secondary Care. All electronic referrals are sent via SCI Gateway. evetting The process where referrals can be examined using software by Consultants and/or a multi-disciplinary team. The appropriate clinical urgency, pathway, and actions required are recorded as the outcome of the evetting process. The software being used in NHSL is called evor. GPwSI A General Practitioner with Special Interests who undertakes patient care which would normally be performed by a Consultant. Implied Occurs where the patient is deemed to have accepted a written Acceptance offer without any further communication required. The patient is given a period of time to decline the offer. Intersystems The company (Intersystems) and software (Trakcare) which will Trakcare PMS replace the current isoft PMS from February 2011. In addition to enhanced provision of existing PMS functionality the system will enable the creation of an Electronic Patient Record (EPR) and support the full tracking of patients along a RTT clinical pathway. NHSL wide clinical order communications will be introduced later in 2011. 5

New Ways Non-Admitted pathway Pathway Patient Focussed Booking Patient Management System (PMS) Reasonable offer Referral Referral Management Service (RMS) Referral to Treatment (RTT) SCI Gateway Stage of Treatment A set of guidance and methods for defining and measuring waiting times in Scotland from 1 January 2008. A RTT pathway where the waiting period stops when a patient receives treatment which does not involve admission as an inpatient or day case. The clinical journey which a patient follows from referral to treatment and beyond for any ongoing care or reviews. A pathway is likely to be made up of a number of interactions or components e.g. outpatient appointment, diagnostic test, preassessment, admission for treatment A process where patients are invited to contact the service to arrange an appointment or admission. More usually implemented where booking outpatient appointments. Software designed to support the management of patient care within NHSL. The current isoft PMS provides functionality to support operational management of patient identification, referrals, waiting lists, scheduling, appointments and admissions, case note tracking, and bed management. There is limited support for clinical order communications at Wishaw only. The next software release will improve electronic receipt of referrals and capture of UCPN (14.4 in June 2010). isoft PMS will be replaced by Intersystem Trak in February 2011. Up to two dates of appointment or admission with 7 days or more notice from the date the offer is made. A referral is a request to a care professional, team, service organisation to provide appropriate care to a patient/client. Provides a central contact point (based on Hairmyres site) for receiving and processing the majority of referrals received by NHSL. Also books the majority of new outpatient appointments. Also known as 18 weeks, this is the waiting time standard for a patient s whole journey from initial referral for a condition to treatment due to come into force in December 2011. An NHSScotland wide system to provide secure communications between GP and Secondary Care systems. Used to transfer clinical and demographic information as part of the referral process based on agreed protocol templates. A component part of a full clinical pathway. Currently national waiting time measurement and reporting are against the new outpatient, inpatient, and some diagnostic stages of treatment. Straight To Test A RTT referral directed to diagnostics services where the patient will be assessed and might, if appropriate, be treated by a medical or surgical Consultant-led team before responsibility is transferred back to the referring health professional. Treatment and Examples which stop the RTT clock include treatment as an care activities inpatient or day case, treatment in an outpatient setting including surgical, medical, and non-consultant led activity, supplying and fitting of a medical device, no treatment required, active monitoring, or patient declines treatment. Unavailability A period of time when the patient is considered unavailable for attendance or admission for social or medical reasons. The days that a patient is unavailable are not counted when determining 6

Unique Care Pathway Number (UCPN) Waiting Time calculations how long the patient has waited. When a patient is unavailable the waiting time clock can be said to be paused. An identifier unique to each RTT referral which was established to enable linkage of components of a RTT pathway to improve tracking and measurement. Referrals received via SCI gateway referrals contain a UCPN however the next release of isoft PMS (14.4) is required before the UCPN can be recorded in NHSL. Stage of treatments are calculated as the days elapsed from receipt of referral or addition to an inpatient or day case waiting list until the patient attends an appointment or is admitted. If a patient cancels (CNA or DNA) the clock will be reset and the waiting time counted from the date of the cancellation until attendance or admission. In addition any periods of patient unavailability will be removed from the calculation. 7