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FAIR TO ALL, PERSONAL TO EACH The next steps for NHSScotland
Chapter 3: Quicker. Better Care
3.1 We have laid the foundations and have made a start towards shorter waits. Now we need to do more to reduce waiting and to reinforce quality across all stages in the patient's experience of care and treatment. These stages begin with initial contact with a practice team at the local GP surgery or the community pharmacy, through diagnostic tests, seeing a specialist as an outpatient, and on to treatment as an inpatient or day case patient where necessary.
Primary Care
3.2 Recent figures illustrate the very large number of contacts already taking place: 26 million in the year ended March 2004, of which over 15 million were with GPs and over 9 million with practice nurses and district nurses. This represents over 90% of patient contacts with the NHS. We will
continue to ensure that the 48-hour maximum wait target is delivered for the benefit of patients all over Scotland. This pledge will remain in place as numbers of consultations and patient contacts in primary care increase.
3.3 With service redesign and the expansion of staff roles, primary care staff will undertake more procedures. These range from drawing blood for diagnostic testing to undertaking minor surgery. And more people will have access to a wider range of services in their local surgery - provided for example by specialist nurses - that might previously have required a hospital visit.
3.4 Local diagnostic and treatment centres - such as Leith Community Treatment Centre in Edinburgh and Stracathro Hospital in Angus - are already able to offer local access to diagnostic services such as X-ray and endoscopy. This for many patients is a more convenient alternative to a hospital visit. We expect to see more local diagnostic and treatment centres develop as Boards work to ensure that waiting times targets are met.
Shorter Waits for Diagnostic Tests
3.5 Shorter waits for diagnostic tests and procedures will make a vital contribution to shorter waits overall. Up to now, the NHS has had no standards for waiting for routine diagnostic tests. So a patient might move rapidly to see a specialist as an outpatient but then wait months for diagnostic tests. Waiting can vary widely between different tests (eg MRI scans, barium meals, endoscopies - internal examinations using a micro-camera) and between different NHS Board areas. This is a frequent source of frustration to patients, who must put up with stress and uncertainty until a diagnosis is confirmed.
3.6 We aim to consign that to the past. We
have decided to set new waiting time standards for key diagnostic tests. We are working with the NHS and others to decide what these should be and from when they will apply - but they will have the effect of reducing longest waits substantially. We will set and announce the new standards by Spring 2005. We aim to set these waiting times standards ahead of any other part of the UK, and will begin to measure and report performance as soon as possible.
3.7 Better IT, wider roles for nurses - in for example endoscopy services, more diagnostic capacity, and clear standards backed by performance management actions will all help ensure shorter waits.
Janice is a nurse endoscopist. To help tackle long waits for endoscopy, which has in the past been carried out by consultants, she trained last year to provide this service for patients. So far she has seen over 800 patients. They would otherwise have had to wait to see a consultant. With the success of the service Janice is now training to provide 2 additional types of endoscopy. Four other nurses in the NHS Board area are now training so they can expand this service further. |
Shorter Waits for Outpatients and Inpatients
3.8 Waiting to be seen by a specialist or for treatment is not only frustrating, it can make a clinical condition worse, and mean that someone has to bear pain or disability for longer than they need to. So we have decided to set new, shorter outpatient and inpatient waiting times targets. Meeting these will take the NHS further in the direction of providing responsive, patient-centred services. The new targets are for
a reduction to an 18 week maximum wait for both outpatients and hospital treatment by end-2007. These new targets are tough but achievable because of reform and the new resources we are putting in. We estimate that achieving a maximum 18 week wait for hospital treatment and for outpatients
will benefit around 270,000 patients in Scotland each year.
3.9 Meeting the new targets will require new ways of working to increase NHS productivity while maintaining quality standards. There are already examples of sharp reductions in waiting times through service redesign. The challenge is for all parts of the NHS to come up to the level of the best.
John has suffered from psoriasis, a skin condition, for 12 years. It flares up from time to time and he has had routine appointments over many years with the consultant dermatologist in Dumfries. The problem is that flare ups rarely happen at the time of his 6 monthly check-ups and travel to the hospital is 20 miles return. Following a review of how the outpatient service was organised, John now receives a phone call periodically from the consultant to check on his condition. He no longer travels at 6 monthly intervals to the hospital. If a flare up happens he gets an urgent appointment quickly instead of a routine appointment when there may be little need. |
3.10 Illnesses that require urgent intervention like cancer and heart disease will continue to have their own shorter waiting times targets, so that patients will be seen and treated more quickly.
3.11 Expanded roles for healthcare staff are already making a vital contribution to shorter waits. We are also encouraging active benchmarking and other performance improvement actions among NHS Boards so that systematic progress can be made. If the reasons for variations in performance are understood properly, it is easier to improve performance in areas that are behind the best. We expect NHS Boards to take a close interest in performance improvement through benchmarking.
3.12 Strategic investment in IT will also help reduce waiting by improving efficiency, automating manual processes, and ensuring that the right information arrives where it is needed on time.
Targets for Specific Conditions
3.13 In addition to the new maximum overall wait targets, we will introduce new targets for condition-specific maximum waits. We are setting a
new stretching but achievable target for cataract surgery. The maximum wait from referral by a GP or optometrist to surgery will be 18 weeks. This will be implemented across the NHS in Scotland by the end of 2007, bringing significant quality of life benefits to the 20,000 or so patients who need cataract surgery each year.
3.14 We are also introducing
a new waiting times target for patients seen in Accident and Emergency Units: from the end of 2007, patients will wait no longer than 4 hours between arriving at a Unit and admission, discharge or transfer, unless there are stated clinical reasons for keeping the patient in the Unit. This maximum wait will also apply to all other emergency care in minor injuries units or areas of assessment units where trolleys are used.
3.15 When someone fractures their hip, risks are reduced and recovery is helped by undergoing surgery as quickly as possible. NHS Quality Improvement Scotland has already set a clinical standard that a patient entering a specialist orthopaedic unit for surgery following hip fracture should be operated on within 24 hours of admission. From the end of 2007, all orthopaedic departments handling trauma cases will comply with the
24-hour surgery target for hip fracture cases, unless there are documented clinical reasons relating to the patient's condition that make this undesirable.
3.16 As we made clear in the early autumn, we have made a commitment that
from the end of 2007, no patient will wait more than 16 weeks for cardiac intervention. This target covers the period from GP referral through rapid access chest pain clinic or equivalent, to cardiac intervention thereafter.
For the first time, our new target includes the period following the GP referral and will cover more heart treatments, including heart valve surgery. It is a reduction by 10 weeks on the current target and is significantly shorter than is available anywhere else in the UK. But more importantly, it will bring direct benefit to hundreds of patients and it will be achieved for them by the end of 2007.
3.17 But heart problems can show themselves in other ways than chest pain. To ensure that the full range of cardiac interventions is available to patients as quickly as possible, we are putting in place a further target.
From the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment.
Sylvia attended a surgical outpatient clinic in Glasgow in October 2002, where she met a surgeon to discuss her case. She had bypass surgery 15 weeks later in January 2003 - well within the previous target time of 24 weeks. This was a step change from the situation prior to 2002, when there were no formal waiting time targets at all. Henry, for example, had angiography in January 1999 and then had to wait over a year until February 2000 for bypass surgery. Since June 2004, we have brought waiting times for all patients to the kind of level that Sylvia experienced - no patient will wait more than 18 weeks for bypass surgery or angioplasty. |
Clearer and More Consistent Definitions
3.18 By the end of 2007, the NHS in Scotland will calculate patients' waiting times on a different basis that will be
fairer, more open to scrutiny, more understandable, and which will help put patients at the centre of their care. Waiting times will be calculated from the date a patient is placed on the waiting list to the date of an outpatient appointment or hospital admission for treatment. Availability status codes - which at present mean that some patients waiting for highly specialised or low priority treatment wait longer than the maximum waiting times - will be abolished. Patients who are waiting for such treatments will be admitted within the same maximum waiting times period as all other patients. Patients will have any periods of unavailability for medical, social or personal reasons subtracted from the calculated waiting time. Periods of unavailability will be reviewed regularly, so that no-one will remain unavailable for treatment for more than 3 months without a check on their status.
3.19 The new arrangements also mean that patients have to take responsibility for accepting and keeping a reasonable offer of an outpatient consultation or hospital admission for treatment. Patients who fail to turn up for an appointment or admission without prior warning will return to the start of the waiting queue, unless there are clinical or other compelling reasons for treating them more quickly. Effectively they will have their waiting times "clock" returned to zero. New patient-focussed booking systems, now being introduced across the NHS in Scotland, will help to ensure that patients have the opportunity to choose an outpatient appointment that is convenient.
3.20 These are huge changes and will bring substantial benefits to patients. Ending availability status codes means that no patient will be placed outside our waiting times commitments and very long waits will be eliminated. The arrangements will be open and transparent and will ensure fairness and consistency across Scotland. Patients will receive better information about what they can expect from the NHS in terms of maximum waits, about any change in their status, and what will happen next and when.
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