Large scale workforce change briefing The 18-week wait programme Findings, successes and learning from NHS Employers large scale workforce change 18-week programme This Briefing summarises some of the findings, successes and learning from NHS Employers large scale workforce change (LSWC) 18-week wait programme. The programme ran from August 2006 to June 2007, with 25 trust teams participating in service and workforce redesign to develop effective pathways for patients, with the aim of achieving the 18-week target. All teams achieved this target in the areas on which they focused. This Briefing details the evidence and learning achieved by trusts on this programme, successes achieved and how these were obtained, and some top tips for success at achieving the 18-week target. It will be particularly useful for board members and those responsible for delivering the 18-week target in NHS organisations. Key findings Within ten months, all teams using the methodology and skills taught by the LSWC programme achieved the 18-week target in the areas on which they chose to focus. Teams reported significant reductions in waiting times. On average, teams reported a ten-week or 63 per cent reduction in waiting times. The greatest reduction in waiting times achieved on the programme was 30 weeks. Some teams, who started the programme with an already-lower waiting time than most trusts, reported a 92 per cent reduction in their waiting times. After ten months, nine teams appropriately removed 4,000 people from their combined waiting list an average of 61 per cent across their waiting lists. The greatest reduction achieved by one team was 1,000 patients an average of 78 per cent. Even the least reduction achieved was still very significant, at 15 per cent of the organisation s waiting list. The trusts did not have to invest heavily in introducing new roles or spend funds on new equipment. Many of the improvements achieved resulted from simply looking at processes and systems and revising and updating them. A part of the NHS Confederation working on behalf of the NHS Employers
Background The Government introduced the 18-week target in 2005, which was to deliver an 18-week patient pathway from GP referral to the start of treatment by the end of 2008. The LSWC programme, run by NHS Employers, aimed to support trusts in achieving this target by enabling them to develop local improvements and solutions to achieve their targets. How was this achieved? The LSWC methodology, which has had significant success and has helped make huge service impacts in the NHS in the past, was used to support teams to deliver service improvements. This programme adopted and adapted experiences from previous programmes, and provided the workforce and service with redesign solutions to enable the teams to meet their organisation s needs. The teams were taught improvement skills and diagnostics, given service and role redesign training and were assisted in measuring their progress, outcomes and the impact of the changes made at their organisation. What was needed The trusts did not have to invest heavily in the introduction of new roles or spend funds on the introduction of new equipment. Many of the improvements achieved by trusts through the LSWC programme resulted from simply looking at the processes and systems that their organisations had developed historically, and then revising and updating them. Additionally, ensuring current policies and procedures were implemented effectively helped trusts to achieve significant reductions in both waiting times and waiting lists. What approach was taken Teams on the programme used various methods to bring about their improvements. Some teams took a health community approach to redesign the patient pathway, engaging all major stakeholders. The majority of the teams decided to look at patient pathways through individual departments across a range of specialties, including neurophysiology, radiology, cardiology, orthopaedics and cholecystectomy. All teams carried out process mapping and capacity and demand profiling to examine the working practices throughout their chosen departments. Carrying out small-scale changes enabled teams to ensure they had the right people doing the right job at the right time. Many of the improvements involved new ways of working and service redesign rather than the introduction of new roles. Many trusts took the approach of validating waiting lists. In many cases this simply involved removing patients who were on the list twice, appropriately removing individuals where there was no clinical need identified and working with clinicians to ensure that only appropriate referrals were received. Additionally some trusts assessed where patients did not turn up for clinic appointments. Some teams found that patients had been given up to seven repeat appointments even though they had not attended any previously-arranged appointments. Once this issue was resolved appropriately, with patients needs as a priority, it reduced the amount of wasted clinic slots that could then be offered to other patients, freeing up the waiting lists. 2
Sharing the learning to achieve the 18-week target Top ten tips Much was learned during the programme, as trusts improved and redesigned services to ensure that patients were given a better experience. Here we share some learning from the programme to support you in meeting your own 18-week target. If you cannot do anything else to help achieve the target, ensure that you put these ten steps in place to achieve short and long-term benefits within your organisation. 1. Validate your waiting lists and ensure systems are in place to stop errors reoccurring. This ensures only patients who require treatment are recorded on your waiting list. 2. Manage your do not attends (DNAs) and cancellations effectively and ensure that current polices in this area are followed. This will mean you do not waste clinic slots with repeat offenders, which frees up your waiting lists. 3. Gain ownership for service improvement within your department by ensuring all the clinical team, including consultants, are engaged. Evidence from the programme suggests that service improvement won t happen without this level of engagement. 4. Understand your departmental activity by carrying out a capacity and demand profile (you can get help with this from the NHS Institute for Innovation and Improvement at www.nodelaysachiever.nhs.uk). This will ensure that you are using all your resources to their full potential. 5. Map the full patient pathway from referral to treatment and make sure you identify all the stakeholders involved. Without their engagement it will be difficult to make progress. 6. Establish full or partial booking systems across pooled waiting lists to reduce the number of patients waiting. Giving patients choice leads to fewer of them not attending. 7. Look to develop your support staff by reviewing job descriptions as administration processes are essential. Evidence from the programme suggests that many clinical staff undertake clerical duties at the expense of their clinical duties, which reduces the effectiveness of the service. 8. Ensure good quality information systems and measurements are in place to identify areas for improvement and to monitor progress. 9. Ensure timely and appropriate communication to highlight what you are trying to achieve and what you do actually achieve. Good quality information shared with the appropriate people will show you where to target activity to achieve the most significant improvements. 10. Patient education is essential when significant reductions have been achieved, otherwise DNA rates and patient anxiety will increase. Evidence from the programme indicates that patients fear they are acutely ill if they are called back for appointments within a short time. Therefore, there needs to be education for patients on this new way of working and the impacts it has on them. 3
Successful case studies Some of the teams achieved tremendous and significant results after ten months of learning on the LSWC programme, with very little investment. Here we describe some of the trusts results and learning to show what they did, how they did it and what they achieved as a result. Every participating team s case study can be found at NHS Employers website www.nhsemployers.org/kb/kb-785.cfm Barts and The London NHS Trust Barts and The London NHS Trust is an acute trust with 1,100 beds, serving a population of 5,000. The team on the programme focused on meeting the 18-week target in the area of neurophysiology. By the end of the programme in April 2007 this had been reduced to only ten weeks, both meeting the 18-week target and reducing waits for patients by an incredible 30 weeks. What they achieved They reduced the size of the waiting list and the amount of time patients had to wait for treatment, as well as reducing DNA rates. When the team began the programme in June 2006, the waiting time for patients to get treatment was 40 weeks. By the end of the programme in April 2007 this had been reduced to only ten weeks, both meeting the 18-week target and reducing waits for patients by an incredible 30 weeks. In June 2006, the waiting list had 1,350 patients on it and after improvements made over ten months The trust had appropriately removed 1,050 patients off its waiting list. on the programme, the trust had appropriately removed 1,050 patients off its waiting list. Other benefits included more engagement from consultants and other clinical staff and a 50 per cent reduction in non-attendees at the outpatient clinics. How they achieved it The team used a number of ways to achieve their target. They: validated waiting lists and developed models to achieve defined 2007 and 2008 targets managed their planned reductions by using an evidence-based approach reconfigured their booking system created advanced training slots for specialist registrars (SpRs) to increase clinic slots enhanced extended roles for clinical physiologists and clinical scientists refined IT systems interacted closely with main service users to improve communication and referrals redefined service contracts where appropriate to reflect the work being undertaken and ensure the appropriate income levels were received. Benefits achieved for patients and staff Not only did the LSWC programme ensure that the 18-week target was achieved, the following 4
improvements made throughout the programme also benefited patients and staff: closer management of outpatient slots made it easier for staff to feel in control of waiting times and lists improved triage of referrals based on clinical prioritisation enabled the most appropriate patients to be treated earlier more effective use of resources better matched capacity to demand fewer telephone enquiries from patients meant that staff were able to focus on their clinical duties, improving care for patients reported enhanced patient satisfaction within the clinical service improved both staff morale and showed that patients were happy with the care they had received improved appointment system through partial bookings reduced the DNA rates and ensured patients had choice over when to be seen reduced waiting times meant patients got treated quicker, improving their overall health and well-being. The Ipswich Hospital NHS Trust Ipswich Hospital NHS Trust is a large acute trust with 660 beds and a 340,000 population. The team focused on achieving the 18-week target through the echocardiography department. What they achieved They reduced the time that patients had to wait for treatment and reduced the number of patients waiting for treatment. In August 2006, the waiting time for patients was 21 weeks, but by the end of the programme in June 2007 there was no waiting time. It is worth mentioning that although this is clearly a great achievement for the trust, having no waits requires a different way of planning services and some education of patients. Some patients found that being offered their treatment immediately increased their anxiety as they were expecting some time to get used to the idea of treatment, and by being told they were to receive treatment straight away caused them to believe that they were seriously ill. Therefore this requires some education of patients. The trust reduced the number of patients waiting for treatment from 414 in August 2006 to 66 in February 2007. Through the programme they achieved their access target (which was their own trust s target) for diagnostics in this department and overall reduced the backlog in clinics. How they achieved it The trust achieved their successes on the programme in various ways. They: appointed a new echocardiography manager to manage the department introduced a new referral form, which meant that the number of inappropriate referrals were reduced introduced a better balance between inpatient and outpatient activity to match demand. Staff experienced improved working lives from being able to leave clinics on time and having reduced stress. 5
Patients did not have to wait as long for their treatment, if at all. Benefits achieved for patients and staff Patients and staff at the trust also benefited from the improvements made. staff experienced improved working lives from being able to leave clinics on time and having reduced stress staff experienced greater job satisfaction because they no longer had to deal with inappropriate patients or inappropriate clerical duties patients did not have to wait as long for their treatment, if at all there was a more rapid diagnosis of patients conditions in the future patients may benefit from the possible of introduction of a one-stop echocardiography service, due to evidence gathered on the programme to support this initiative. The Royal Liverpool & Broadgreen University Hospital NHS Trust This acute trust has 1,011 beds and serves a population of 300,000. The team focused on achieving the 18-week target through the urodynamics department. What they achieved They significantly reduced both the size of the waiting list and the amount of time patients had to wait for treatment. In June 2006 there were 69 patients waiting over 13 weeks from referral to treatment. By March 2007 this had been reduced to only two through simple changes. Additionally 96 patients were removed from the waiting list for treatment between June 2006 and March 2007, due to small improvements made to processes. Other benefits realised by the trust included improved staff morale and a reduction in patients not attending clinics. How they achieved it They achieved these results through: implementing a do not attend policy validating their waiting lists merging three waiting lists so that overall they were managed more effectively identifying a second practitioner and training them to support the team implementing partial booking systems responding to suggestions made in the patient survey sending patient information leaflets with partial booking letters, to educate patients. Staff were developed and new skills were learned. Benefits achieved for patients and staff Patients and staff both benefited in different ways: staff were developed and new skills were learned succession planning was introduced to manage staff expectations 6
Patients experienced improved waiting times and choices, along with quicker diagnosis. staff felt more able to provide a higher quality of care fewer patients not attending meant staff were able to see and treat more patients patients experienced improved waiting times and choices, along with quicker diagnosis. Conclusion All trusts were able to achieve the 18-week target in the areas on which they focused throughout the programme. With very little investment, by making simple improvements trusts significantly reduced their waiting lists and waiting times for patients within ten months. Across the programme, trust waiting lists were reduced by an average of ten weeks and in nine trusts 4,000 patients were appropriately removed from their combined waiting lists. To achieve this, the trusts did not have to invest heavily in introducing new roles or spend funds on new equipment. Many of the improvements achieved by trusts through the LSWC programme resulted from simply looking at the processes and systems that their organisations had developed historically, and then by revising and updating them. There is some significant and important learning that other trusts can benefit from, as a result of this programme. More information, including case studies, are available on our website at www.nhsemployers.org/kb/kb-785.cfm Future work Although many of the teams have made significant improvements while working on the programme, all of the team leaders recognise that their work must continue if the improvements are to be sustained. Many of the teams are transferring the working models they have developed through the programme to other areas to bring about improvement. They are also utilising the skills and methodologies learned through the programme in other work areas to bring about further improvements. Further information If you would like to find out more about how the LSWC programme was run and the achievements and learning realised, contact Ian Pritchard, programme lead at ian.pritchard@nhsemployers.org You can find good practice case studies from all participating trusts on NHS Employers website at www.nhsemployers.org/kb/kb-785.cfm, along with more about the programmes the large scale workforce change team are running this year. 7
NHS Employers NHS Employers is responsible for workforce and employment issues, working on behalf of NHS organisations in England. We help employers improve the working lives of NHS staff as a path to better patient care. We represent employers views and act on their behalf in the current priority areas of: pay and negotiations planning and workforce productivity employer of excellence HR policy and practice. NHS Employers is part of the NHS Confederation the independent membership body for the full range of organisations that make up the modern NHS. Contact us For more information on how to become involved in our work, email getinvolved@nhsemployers.org www.nhsemployers.org NHS Employers 29 Bressenden Place London SW1E 5DD 2 Brewery Wharf Kendell Street Leeds LS10 1JR When you have finished with this briefing please recycle it This Briefing is available in pdf format at www.nhsemployers.org/publications Published July 2007 NHS Employers 2007. This document may not be reproduced in whole or in part without permission. The NHS Confederation (Employers) Company Ltd Registered in England. Company limited by guarantee: number 5252407 This briefing is printed on 75% recycled paper Ref: EBR103401