Appendix-2012-45 Borders NHS Board MANAGEMENT OF WAITING TIMES Aim This paper aims to provide the Board with a clear picture of how Waiting Lists are managed within NHS Borders. Background NHS Borders have always regularly monitored Waiting Times against national targets using appropriate national guidance, however recently there has been additional focus on this nationally. Summary Waiting Times within NHS Borders are managed in a way that is in keeping with the letter and spirit of the national guidance, and where these are unclear there is a local procedure manual in place. Operationally any issues which emerge during the year or revisions to national guidance are dealt with by the Access Management Group in the first instance. Recommendation The Board is asked to note this report Policy/Strategy Implications Consultation Consultation with Professional Committees Risk Assessment Compliance with Board Policy requirements on Equality and Diversity Resource/Staffing Implications Review of Waiting Times management processes 1
Appendix-2012-45 Approved by Name Designation Name Designation Jane Davidson Chief Operating Rachel Bacon General Manager - Officer Acute Author(s) Name Designation Name Designation Steven Litster Waiting Times Coordinator 2
Management of Waiting Times Aim This paper sets out the current position of NHS Borders Waiting Times and gives an overview of the processes which are in place to manage these. Background There are a number of individual targets currently in operation however this report comments exclusively on Stage of Treatment, 18 Weeks Referral to Treatment and Cancer Waiting Times. Stage of Treatment Targets The national Stage of Treatment (SOT) targets are that all outpatients should be seen within 12 weeks of referral, and patients listed for inpatient / day case surgery should receive this within 9 weeks of being added to the waiting list. At 31 st March 2012 NHS Borders achieved these targets, with the exception of two inpatient / day cases and one outpatient (one of these patients declined treatment prior to 31 st March, one was medically unfit to receive treatment and one instance was due to an administrative error). This level of performance positions NHS Borders in a positive position when benchmarked nationally. The tables below have been extracted from the national publication of the end March position, with April performance also shown, although the information is not yet published: Inpatients Jan-12 Feb-12 Mar-12 Apr-12 Number on List 916 903 932 910 Number Waiting >9 Weeks 87 50 2 0 Outpatients Jan-12 Feb-12 Mar-12 Apr-12 Number on List 4,241 3,868 3,740 4,212 Number Waiting >12 Weeks 453 244 1 0 The current forecast position for 31 st May shows that stage of treatment targets will continue to be successfully met. 18 Weeks / Referral to Treatment Target The 18 Week / Referral to Treatment standard came into effect from December 2011. The target states that 90% of patients should receive first treatment within 18 weeks of referral. The table below shows NHS Borders performance during the first three months of 2012: Percentage Achievement of Target Jan-12 Feb-12 Mar-12 Apr-12 (provisional) Non-Admitted 93.2% 93.9% 94.7% 95.4% Pathways Admitted 76.4% 77.8% 79.8% 75.2% Pathways Overall 90.2% 91.5% 92.1% 92.2% This new target was successfully achieved during the first three months of 2012, although there is room for improvement around admitted pathways (i.e. those patients for whom first treatment would be an operation) and plans are being put in place to achieve this over the next few months. Cancer Waiting Times ~ 1 ~
The national cancer waiting times target is that all patients referred with suspicion of cancer should receive first treatment within 62 days of referral, and all patients diagnosed with cancer should receive first treatment within 31 days of decision to treat. Percentage Achievement of Target Jan-12 Feb-12 Mar-12 62-Day Patients 100% 95% 100% 31-Day Patients 100% 100% 100% Year End Position NHS Borders ended the financial year broadly delivering agreed waiting times targets, and this is expected to continue into 2012-13. There are particular challenges around capacity in Dermatology and ENT which are being addressed through our Demand and Capacity work, and Orthopaedics which is the focus of a separate project around the recruitment of an additional consultant and team of middle grade doctors. Approach to Delivery of Targets During 2011-12 During 2011-12 there was a distinct change of emphasis, moving away from delivering Stage of Treatment targets using short term waiting list initiatives towards measuring waiting times across an overall patient journey, using Demand and Capacity modelling to identify sustainable longer term solutions. The decline in Stage of Treatment performance reported during July December 2011 can be partially attributed to the challenges involved in implementing this work, and this had a significant knock-on effect in the volume of additional activity that was required during the first three months of 2012. During this year NHS Borders also moved toward an improved position on how it commission ed waiting list initiative work, began to place greater emphasis on measuring patients overall waits (in addition to the waiting times as measured according to national guidance) and strengthened the procedures around offering patients the opportunity of treatment at external locations (such as Golden Jubilee). Historically there have been some cases where NHS Borders has carried significant backlogs due to capacity shortages, particularly around ENT and Orthopaedic inpatients where on occasions waiting times for treatment locally have reached 9 12 months. In these instances patients were offered the opportunity of treatment at an alternative location within their stage of treatment target at an alternative provider, usually Golden Jubilee, Glasgow Nuffield or Woodlands Hospital in Darlington. Where this option was declined, as per national guidance this would record the patient as unavailable until an appropriate appointment was available locally. Although this would result in no detriment to the patient when being offered an appointment locally, where there were lengthy waiting times this could result in the period of unavailability being amended. Following recent initiatives, principally employment of a full time Orthopaedic locum and ENT locums on a part-time basis, significant inroads have been made into these backlogs, so that now the targets are broadly being met within local capacity, and recently only a small number of patients have been offered treatment externally. Where patients choose to wait for treatment locally this is now considered as declining a reasonable offer of an appointment and the patient s waiting times clock is reset. Rather than always sending these patients back to start again, where patients express a positive desire to wait for treatment locally, and if we have future capacity, we do try to accommodate this where there is an appointment available, even if just beyond the guarantee date. This is done by recording unavailability (in accordance with national guidelines). The lessons learned during this period will be invaluable as we seek to balance putting in place solutions which are sustainable in the long term whilst continuing the achieve targets in the short term. How We Manage Waiting Times ~ 2 ~
Acute Waiting Times within NHS Borders are primarily managed by the Waiting Times team within Borders General Hospital. There are regular weekly and monthly meetings where operational and capacity issues are discussed with the General Manager Acute, and Service Managers. A monthly meeting of the Access Management Group chaired by the Chief Operating Officer to provide strategic overview. Audit of Waiting Times Management Following coverage in the national press the Scottish Government has requested an in depth assessment of waiting times management processes across Scotland. The outcome of the last NHS Borders Internal Audit two years ago was a satisfactory rating, with the only particular area of concern being around monitoring of 18 week pathways. Reviewing the content of the PWC report into NHS Lothian Waiting Times highlights a number of issues, and whilst there is no suggestion that similar practices are being followed in NHS Borders, some processes have been identified as requiring improvement. The particular areas of concern highlighted in the PWC report related to: 1. Use of Periods of Unavailability PWC found that in NHS Lothian significant periods of unavailability were being applied retrospectively to prevent patients being reported as breaches with no evidence to support these changes. In Borders there are some issues relating to the application of unavailability, discussed earlier in this report, where information on the computer system isn t always kept up to date, leading to unavailability being applied retrospectively, but there is no suggestion that this is being done inappropriately. A review is currently underway of practices to ascertain whether some patients are being listed inappropriately for surgery, for example where they are known to be medically unfit for surgery or wish to defer treatment for extended periods. 2. Reporting In NHS Lothian information supplied to Senior Managers and through reporting lines to the Board was inconsistent with that available to Service Managers. In NHS Borders all information reported internally is extracted directly from Trak, although there are a small number of amendments made due to locked records on Trak. This is due to a particular problem with Trak, which will be resolved through the next system upgrade. 3. Culture and Governance In NHS Lothian the report states that there was a culture of no bad news, and clerical and lower level management staff were pressurised to find tactical solutions to waiting list problems. In NHS Borders there are regular meetings with General Manager and Service Managers to discuss and identify solutions to Waiting Times issues. During the year revised processes were put in place to ensure appropriate authorisation and review through the management lines to the Chief Operating Officer, of Waiting Times issues and outturns. Greater emphasis on Demand and Capacity work will ensure that all potential capacity problems will be openly identify and highlighted at the earliest possible opportunity. 4. Trak System Controls ~ 3 ~
NHS Lothian Senior Management had limited access to information available through Trak reports, giving little oversight that reports were amended between management levels. There are reports available through Business Objects which are available to senior managers within NHS Borders. However at present there are some issues with data quality on these reports, relating to the data items mentioned in (3). This is currently under review. 5. Working Practices and Guidance NHS Lothian had no finalised Waiting List Management Policy which reflected the implementation of New Ways guidance in 2008. NHS Borders put in place a revised Waiting Times Management Protocol to reflect the implementation of New Ways in 2007, and this was most recently revised in January 2011. As stated earlier in the report, action has already been taken to revise the processes which are used when patients decline the opportunity of treatment outwith NHS Borders (the main area of criticism in the PWC report), with further work ongoing around how patients who are unavailable for treatment are managed (through the scheduling projects) and some system configuration issues. The terms of reference for the Internal Audit to be held in August 2012 centre around ensuring that information held on the Patient Administration System is consistent with that held in the patient s casenotes and that there are processes in place to manage waiting times appropriately, including checking that information available to all levels of management (from operational staff to Scottish Government) is consistent. A second audit will also be carried out by Audit Scotland, which will focus on retrospective application of unavailability, although the full scope and methodology of this audit has yet to be developed. Anticipated Outcome for NHS Borders There are three main areas of concern that are likely to be highlighted locally as a result of the Audits that will be undertaken during 2012. These are: 1. Retrospective application of unavailability There are issues locally around retrospective unavailability as a significant amount of patient scheduling is carried out using paper based systems which are then replicated on the computer system, rather than the computer system being the primary system. Whilst there is no suggestion that unavailability is being applied incorrectly, it is often applied retrospectively in batches. Historically this often also happened where patients were offered and declined the opportunity of treatment at another hospital. To ensure that there was no detriment to the patient being offered an appointment locally as a result of declining treatment at another location, an appropriate period of unavailability would be applied after the patient had accepted a local appointment to ensure that this would not be reported as a breach. This was in accordance with national guidance and alternatively could have been recorded as a clock reset, but would be reported as unavailability being applied retrospectively. There are also issues around the degree flexibility offered when managing patients who either make themselves socially unavailable for periods of time or who are medically unavailable for lengthy periods. A review is underway of the process around both these groups of patients, as it is felt that these could be significantly improved. 2. Unknown Waits of 18 Week Pathway Patients Measurement of waiting times against 18 week pathways is carried out retrospectively (as this target is based on patients being treated rather than seen), however at present there are only limited processes in place to manage these patients prospectively. As a result of this, there are a number of patients where waiting times cannot be measured (this is a problem nationally, not just in NHS Borders) and it is essential that we put in place systems to achieve this. ~ 4 ~
In the longer term this functionality will be available through the Trak PMS (currently anticipated for March 2013), but it is essential that we put in place some processes before this date. Work is ongoing around this, concentrating initially on measuring overall waits for those patients on admitted pathways. 3. NHS Borders patients treated in Lothian There are particular issues around NHS Borders patients who receive treatment in NHS Lothian as part of an 18 week pathway. Where patients are initially seen within NHS Borders and referred on to Lothian, for example to receive a more specialist assessment of a condition, responsibility for treating the patient timeously remains with NHS Borders (the opposite would be true for Stage of Treatment waits where responsibility for the patients would rest with NHS Lothian). At present we are dependant upon NHS Lothian to monitor that they are treated within reasonable timescales. Addressing this will also become part of the solution to item (2) above. Summary & Next Steps Overall NHS Borders Waiting Times are reporting a good position with plans in place to improve these further. This will centre around four key pieces of work: 1. Local Waiting Times The Waiting Times targets that have been agreed by NHS Borders Access Management Group and we will work to during 2012-13 are: a. No inpatients / day cases waiting longer than 12 weeks for admission (the new national Treatment Time Guarantee) b. 95% achievement against 18 weeks target. c. 95% of cancer patients starting treatment within 31/62 days. d. No outpatients waiting longer than 12 weeks at month end. e. No inpatients waiting longer than 9 weeks at month end. We will aim to achieve 1, 3, 4 and 5 from 1 st April, with performance against the 18 weeks target currently sitting at 90% 95%. To support this work is ongoing to put in place systems to prospectively manage patients against 18 week pathways, particularly for those patients on admitted pathways. 2. Implementation of detailed Demand and Capacity monitoring Processes are currently being put in place to ensure that all services (beginning initially with consultant led services) have a Capacity Model which will show projected demand on the service and a plan of how this will be met. Services will then be monitored against these plans to ensure that these are delivered successfully. The aim is that each service will have a completed and agreed Capacity Model by end September 2012. 3. Implementation of prospective monitoring of 18 week patient pathways Measurement of 18 week pathways is currently performed retrospectively, making it almost impossible to accurately predict and improve future performance. There is a module available within Trakcare to support prospective management of patients against an 18 week pathway, but this is not currently anticipated to be available until March 2013. In the interim work is underway to attempt to monitor some of these patients prospectively outwith Trak. Initially this will be focussed towards those patients on admitted pathways as this is where performance requires most improvement. ~ 5 ~
In parallel work will be carried out to analyse why those patients who breach do so, to identify where efforts should be targeted to improve performance at a whole system level. 4. Improvement of scheduling processes to maximise available capacity. Two significant projects are currently underway looking at our processes for scheduling patients for surgery and for outpatient appointments, to ensure that appointments are allocated appropriately and that clinical capacity is fully utilised. As part of this review we will also be looking at patient unavailability. ~ 6 ~