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08 CHAPTER EIGHT MANAGING ACCESS TO QUICKER PLANNED CARE AND DIAGNOSTICS

A. Planned Care

01 The White Paper, Partnership for Care (2003), stressed the importance of looking at the pathway of care from the patient's point of view to make it smoother, more accessible and less subject to delays.

02 This is both challenging and necessary, given the volume of patients who receive care within NHS Scotland. In 2003/04, around 683,000 patients were discharged following an episode of inpatient care. Of these, 205,000 were elective admissions and 477,000 emergency. A further 360,000 were treated as day cases.

03 Despite all the advances in improving patient access and experience, there is still a lingering perception among patients, with some justification, that their journey remains littered with barriers, pitfalls, duplication and delay.

04 It is worth reflecting on the announcement made by the Minister for Health on 15 December 2004. He said:

'The NHS does a great job for the people of Scotland - and in many aspects offers patients the best service in the UK. But patients rightly expect improvements. It is my job to deliver them and that's what I'm going to do. Over the next three years, there will be significant change to get rid of excessively long waits for good, make the service much more focused on patients and extend choice - fair to all and personal to each. Not so long ago, patients were waiting up to 18 months for inpatient/day case treatment. We've cut that down to 12 and now nine months, reducing to six months by the end of next year. We have met all our previous targets and we will meet those we have set for the end of 2005. Because of that we can now go further: for all procedures, by the end of 2007 no-one will wait more than 18 weeks from GP referral to an outpatient appointment. For inpatient and day cases no-one will wait more than 18 weeks from diagnosis to treatment. Together, these will benefit an estimated 270,000 patients a year.'

05 The bar has been raised for access to elective care and the National Framework will make a contribution towards the achievement of these targets.

06 There is a debate that needs to take place about how the issue of waiting is targeted in the NHS. Internationally, there is clear evidence that speeding patient flow through the system can be delivered effectively in health care just as many other organisations in other sectors deliver quicker services to their customers. In England, much of the early success in reducing waiting has been credited to the National Patient Access Team. Consideration should be given to whether resources for tackling waiting times should be centrally managed or devolved to Boards. We should learn from some of the successes in Scotland and elsewhere - building, for example, on the impact of patient focused booking.

07 One of the main threats to the smooth delivery of much elective care comes from the kind of emergency pressures which have already been outlined. Before a surgical procedure can be carried out, a range of resources have to be brought together at the right time and the right place: surgical staff, nursing staff, anaesthetist, theatre time and a bed. Remove any one of these components, and the operation has to be cancelled.

08 Where the same staff and resources are available for both elective and emergency care, emergency treatment will always come first - because it is an emergency. The need to perform emergency treatment can mean the loss of one or more of these components.

09 This is a further example of where a whole-system solution is required. Stresses in the provision of emergency care have knock-on effects to planned activity causing the frustration of cancellation and delay. To some extent, the answer to providing better and quicker elective care lies in smoothing the mismatch between the variation in demand and supply of emergency care. But it also involves more role enhancement and smarter working, particularly streaming elective care away from emergency care when it is sensible to do so.

10 There has been a progressive transfer of many forms of elective surgery from an inpatient to a day-case setting over the last twenty years. The pattern has been extended as increasing numbers and types of procedure are carried out in an outpatient department or in primary care - endoscopy and minor surgery, for example.

11 This tendency towards localisation of elective care has occurred in part for reasons of efficiency and in part for reasons of patient comfort and convenience. It has involved widening empowerment of staff as surgery has ceased to be the exclusive preserve of surgeons and other hospital-based clinicians, and has provided opportunities for healthcare professionals to widen their skills and the scope of their relationship with their patients.

12 This shift along the spectrum from inpatient settings to primary care can be regarded as the result of creative responses to increasing demand and increasing technological potential. But in many areas - such as the performance of minor surgery in a primary care setting - it is still early days and there is a considerable potential for further shifts.

13 The process has not gone as far in Scotland as it has in England. A recent Audit Scotland Report showed that overall, Scotland has lower day surgery rates than England
(Audit Scotland, 2004).

14 Our work on elective care has identified the need for action in three areas:

• improving pre-admission processes
• streamlining the hospital component
• identifying and rolling out best practice on discharge and after-care.

Pre-admission

15 One of the challenges for the NHS is to incentivise its strategic outputs. Each element of the service has to have a stake in the performance of the others. So, for instance, long waiting times in the acute sector have traditionally been blamed on inefficiencies or inadequate investment in that sector without taking into account the impact of primary care on demand and demand management. Similarly, poor access to diagnostics for primary care clinicians has been blamed on inefficient, poorly managed or increasingly expensive and technical investigation services. Neither sector has had responsibility for health improvement, nor has there been any overview of the patient's journey and the patient's experience. We need to change that approach.

16 The introduction of a shared referral management system adds value for both primary and secondary care. Referral information is the first step to collecting information on demand and to working within primary care and community services to finding alternatives. But to maximise its contribution to the diagnostic process as well as treatment, it is important to design referral management as more than a purely administrative process.

17 Referral management enables a more sophisticated single point of referral from GPs and other healthcare professionals within primary care. The referral management service arranges the most appropriate appointment, either within primary care or at hospital. Pathways can be developed, implemented and monitored, and booking can be added to the process, where appropriate, to maximise co-ordination. GPs can refer patients to GP's with Special Interests ( GP wSI) or to other healthcare professionals within primary care, as well as to the acute sector. This is an excellent opportunity for new Community Health Partnerships to demonstrate a contribution to reducing waiting times.

18 There is also real benefit in extending the principle of referral management beyond the local context. Regional centres for specific waiting time services for elective work in areas such as orthopaedics could be developed, allowing GPs and patients access to all appropriate NHS facilities and expertise. This would also ensure the best use of existing NHS services and give choice at the point of contact.

19 The NHS needs to be more imaginative about the use of imaging, innovations such as mobile MRI scanners, and the skills of primary care clinicians who have developed expertise in areas like endoscopy could be used in the secondary sector.

20 The settings for the delivery of care also need to be reviewed. In Scotland, as in England and Wales, there are huge numbers of new outpatient appointments (approximately 1.2m with 3m follow-up appointments). Eighty per cent of patient contact is with acute hospital care and
70-80% of patients are referred to orthopaedic consultants unnecessarily. The potential for shifting care is significant.

21 Referral Information and Management Services are being piloted from April 2005 in Glasgow and Lothian as part of the Centre for Change and Innovation Outpatients Programme. Experience from England suggests that by sharing up-to-the minute referral, waiting times and capacity information between primary and secondary care, waiting times can be reduced by lessening variation in referral patterns and redesigning services to provide, for instance, General Practitioner with Special Interest services. We recommend that Referral Management is introduced across Scotland, building on initial pilots.

22 We also need to act now to develop alternatives to traditional patient pathways. At present, patients presenting to primary care with signs or symptoms of illness are assessed clinically by a GP. The GP practice or primary care allied health practitioner ( AHP) undertakes an agreed work-up schedule for each clinical scenario. If the GP feels the patient requires further investigation or a consultation in the secondary care sector, a referral is made usually by way of a letter, standard referral form or, in more urgent cases, by telephone.

23 On receipt of the referral, the relevant hospital department confirms that the referral is complete and appropriate through a process of 'vetting' of the referral by appropriate clinical staff. Administrative staff then allocate an appointment slot and send details to the patient by post.

24 The timing of the appointment is dependent on factors such as the level of urgency indicated by the GP on the referral (confirmed during the vetting process) and waiting times. One critical factor is that the number of 'urgent' referrals is related to waiting times. Waiting times of several months generate a high proportion of urgent referrals; waiting times of one to two weeks obviate the need for 'urgent' referral in the vast majority of cases.

25 Patients may be referred to multiple locations within the secondary care sector simultaneously, for instance to a consultant-led clinic, radiology department, and clinical laboratory. There is little co-ordination between departments at present, frequently resulting in the patient making multiple trips to hospital on different days, misleading reporting of waiting times, and unexplained DNAs (did not attend for appointment).

26 Results from tests and consultations are sent back to the GP when available by post. Not infrequently, only some (or none) of the results are available at the time of the GP return appointment. This can result in wasted time and undermines the patient's confidence in the healthcare system at an early stage in his or her journey.

27 This model of care wasn't designed, but evolved around traditional boundaries that exist between departments and primary and secondary care. The GP role in overseeing this complex process is considerable. The burden on the patient trying to cope with illness is magnified by organisational inefficiencies, multiple points of contact and multiple visits.

28 In this traditional approach, the diagnostic pathway chosen by the GP is based on a combination of factors including the clinical impression gained during the consultation, clinical experience of similar cases, individual clinical preferences and services available at the local hospital.

29 To reduce stress and improve the quality of care, a more controlled and co-ordinated approach is proposed. We recommend the introduction of Diagnostic Pathways that will address the problem of urgency by stratifying and managing risk in relation to serious illness/pathology. This, combined with a streamlined administrative process or referral management system, will not only allow for timely diagnosis of serious conditions, but will also facilitate speedy exclusion.

30 The 'Team Diagnostics' approach is more patient centred, as a multidisciplinary clinical team will be configured around the patient to optimise individual care. The 'team' includes staff within traditional primary and secondary care boundaries and in effect removes the interface. The constitution of the team will vary depending on the type of clinical challenge, and the clinical partnership formed will develop and agree local management protocols.

31 Diagnostic Pathways will be optimised to individual clinical scenarios (based on agreed referral criteria and all available diagnostic tools) with an emphasis on using technology appropriately and efficiently. An example would be using CT scanning and a fibre-optic examination as the first line investigation in preference to standard x-rays, if justified by the patient's clinical condition at the time of referral. The new model of team diagnostics includes:

• maximum work-up in primary care
• identifying key diagnostic indicators
• triage on the basis of these
• clear understanding of which imaging and diagnostics routes are direct access and which are restricted following triage.

32 The key principles of this model are as follows:

• Where the differential diagnosis makes it likely that the patient can be managed in primary care, then the primary care clinician should have direct access to the investigations that will support the patient's management.
• Where the differential diagnosis is not deemed to be manageable in primary care, the Team Diagnostic route would apply, including primary care-based advance work-up, triage access with direct pathways to imaging, and surgical or medical intervention.
• Clinicians using an agreed 'patient journey' model including full work-up in the primary care setting and better management of referrals by receiving secondary care will improve patient experience. Primary care clinicians are concerned that using a Referral Management Centre and Team Diagnostics might restrict choice or control. We need to develop a methodology for incentivising primary and secondary care to work together, perhaps by joint incentivisation of patient journeys by patient or by result, or transferring the funding for outpatient services or waiting times to Community Health Partnerships.
• We must locally empower clinical leadership to redesign services. Managed Clinical Networks should reflect local relationships between clinicians across primary and secondary care and further develop safe and effective pathways of care for patients.

33 We referred above to the impact emergency admissions can have on elective care. Repeated case studies have shown, however, that elective admissions are commonly the biggest cause of variation across the system, often being more variable and unpredictable than emergency admissions!

34 Variation in the admission process can and must be managed. Analysis of Scottish hospital inpatient statistics still show significant numbers of patients undergoing an elective operational procedure with a pre-procedure length of stay from 0-3 days. Patients are often admitted at a weekend for an operating list on a Monday or Tuesday, simply to guarantee the bed. Because pressures on emergency beds are highest at the beginning of the week, experienced clinicians will use a variety of strategies to ensure that elective patients scheduled for operation at the beginning of the week will have access to a bed. This practice results in many thousands of wasted bed days.

35 Hospitals need to take a whole-system view of the use of bed resources. Use of the System Watch monitoring package has demonstrated predictable variation in patient workload. This consistently shows the highest numbers on Mondays and Tuesdays with significantly lower numbers towards the end of the week. Hospitals should recognise this and design their elective work flow so that fewer patients are admitted on Mondays and Tuesdays, and larger numbers progressively during the week for those requiring an inpatient bed. Day case procedures and surgery can be evenly distributed during the working week, depending on the capacity of day case units. We recommend that all NHS Boards undertake a rigorous review of emergency and elective workflows and synchronise these to the predicted available beds.

36 Some patients are admitted to hospital in advance of their elective operation so that certain tests and assessments can be carried out prior to the procedure. This might include checking on blood results, x-rays, or an assessment by a consultant anaesthetist. Many hospitals and departments have adopted pre-admission clinics as the way to deal with problems prior to surgery. Pre-admission clinics are usually run by nurses with anaesthetic support for difficult cases. Patients can be assessed for surgery and, if low risk, can be thoroughly prepared with all investigations required beforehand. Corrective action can even be taken, such as prescribing a course of iron tablets to correct anaemia. Pre-admission clinics can also plan the discharge of patients, agreeing with patients the level of community support required, and ensuring primary care and local authority colleagues are notified well in advance of the operation date.

37 Consultant anaesthetists can be available to assess patients at moderate to high risk and undertake necessary investigations or change in clinical care to prepare the patient for surgery. When this is done on an open 'rota' basis, where one consultant is acting on behalf of other colleagues who will actually administer the anaesthetic, this is both efficient and time saving.

38 Patients who are clearly unfit for operation, or whose condition has changed while they have been on a waiting list, may be advised to have their operation delayed for some time to improve their clinical status, or may be advised that the operation is no longer appropriate or too risky.

39 Pre-admission clinics can also be used to support good practice in obtaining informed consent. Experienced nurses will be able to discuss the features of common operations, and even anaesthetics, with patients who have previously been given the information by their surgeons, both verbally at the time of consultation and in writing afterwards. Pre-admission clinics give the opportunity for the patient to ask questions. Appropriately trained nurses can then obtain informed consent which also helps to confirm that the patient actually wants the proposed operation.

40 Well-organised and well-run pre-admission clinics allow patients to be admitted on the day of their procedure, and give surgeons and anaesthetists the confidence that the patient has been properly prepared, informed consent has been obtained, and a discharge date and plan agreed beforehand.

Streamlining hospital stays

41 A streamlined journey for patients will provide:

• a multidisciplinary intervention where appropriate
• consultation, investigation and diagnosis at a single visit
• enhanced communication from start to finish of the journey
• efficient use of resources, particularly theatre time, beds and patient capacity
• optimisation of resources such as staff and equipment.

42 Where possible, outpatient and diagnostic services should be provided in local communities and should be delivered by primary care clinicians aligned to the Team Diagnostics concept. 'Low-technology' diagnostics should be provided at practice level with higher technical diagnostics at community hospitals. It may be necessary to consider access to diagnostics at regional or even national level as a way of improving access and therefore reducing waiting times. This would be particularly relevant where significant investment has already taken place. A robust IT system is essential for any of these developments to happen.

43 We believe that day surgery rates can increase, and variation in day surgery rates needs to be robustly managed out of the system. The growth in the amount of day surgery performed over the last 20 years has been possible due to technological and medical innovations such as less invasive surgery and improved anaesthesia (Hurst & Siciliani, 2003).

44 There are significant advantages to increasing the amount of day surgery:

• care is provided through an evidence-based pathway which in turn is likely to produce better outcomes with reduced rates of healthcare acquired infection ( HAI)
• it is less disruptive to patients and their families and there is a high preference if this option is made available
• it is likely to enable the care to be provided in a local hospital
• staff who are involved in day surgery areas are able to work flexibly with more family-friendly rotas
• nursing staff may have a greater level of autonomy and patient contact as they can be responsible for nurse-led pre-admission assessment, post-operative care and discharge.

45 Comparisons against Scottish targets and with English performance demonstrate that there is still potential to increase day surgery rates, which vary across NHS Boards (Audit Scotland, 2004).

46 Research by the NHS Modernisation Agency suggests that the major reason for slow growth in day case surgery is that hospitals predominantly organise themselves as providers of inpatient care. In their '10 High-Impact Changes' ( NHS Modernisation Agency, 2004), they assert that inpatient care should be the exception in the majority of elective procedures, not the norm. Rather than asking, 'is this patient suitable for day case?', we should ask, 'what is the justification for admitting this patient?'.

47 The variation in day case rates referred to above cannot be explained solely by differences in case mix. Evidence suggests that a sizeable proportion is due to differences in clinical practice. We need to introduce in Scotland a list of suitable day case procedures, such as the Audit Commission's basket of 25 procedures (Audit Commission, 2001) or that approved by the British Association of Day Case Surgeons. Then we need to measure and act on variation.

48 This approach to day surgery is part of our overall drive to shift the balance of care. Our goal is to design a system that ensures the time patients spend in hospital is time that adds value for them. But the change also has the potential to free-up resources. The Modernisation Agency suggests that if we could switch just 4000 patients to day surgery, we would release 5600 bed days and save more than £1m.

49 The NHS needs to look at the separation or streaming of elective care to maximise capacity and reduce the impact of diverted resources to emergency care. One of the major questions we face over the separation of scheduled and unscheduled care is how far the concept of separation (streaming) can be taken. Streaming is the separation of elective care from emergency pressures (through dedicated theatres, beds and staff), reducing cancellations, achieving a highly systematic and predictable workflow, and therefore improving the quality of service to patients. Patient safety has to be at the forefront of any proposal that involves elective care being delivered at a distance from critical care back up.

50 The Department of Health has carried out an initial analysis which groups elective procedures by prevalence of an associated critical care stay. This provides an indication, at a very high level, of what could safely be streamed in a facility which does not have critical care facilities readily accessible. The provisional results are as follows, and are shown diagrammatically in Figure 8.1.

Figure 8.1 Percentage of Elective Care in need of Critical Care

• 89% of elective care by volume requires a critical care stay in fewer than 1% of cases
• 96% of elective care by volume requires a critical care stay in fewer than 4% of cases.

51 These volumes give some indication of what work could be carried out safely in a streamed environment, regardless of proximity to critical care, if risks are carefully managed and with relatively modest predictive filtering out of higher risk patients (such as using ASA/ BMI criteria). The range of procedures which might be streamed in practice will clearly depend on safety factors such as the extent of back-up and proximity to critical care facilities, as well as economic factors.

52 Models are varied, dependent on availability of dedicated resources, access to support departments and proximity to essential services. It follows, therefore, that the implications of separation would have to be individually examined dependent on the service design chosen for a particular health economy.

53 Streaming of scheduled care will undoubtedly provide significant improvement in a range of key outcome indicators in areas such as a predictable and increased workflow, reduction in cancellations, value for money, improved recruitment and retention and, importantly, reduced waiting times for patients.

54 There are a number of different models by which the elements of elective care can be mixed and combined. There is a range of issues that should be addressed fully before any implementation, depending on the model chosen. For example, a purpose built/designed unit will create additional capacity, but may face staffing problems due to national shortages in certain professions. Refurbishment/redesign of existing acute areas has proven very attractive to staff who choose to move from other high-pressure emergency areas on the same site. This, however, may create problems among staff groups.

55 This highlights only a few of the key implications. In an attempt to provide a more comprehensive overview of the risk elements, Appendix 3 in the Elective Care Action Team Report details a range of issues that need to be considered. No assumptions have been made over specific service design - the appendix merely suggests potential risks that would need to be considered, dependent on the patient pathway chosen. The report can be found at www.show.scot.nhs/sehd/nationalframework

56 Streaming can be carried out on a local, regional or national basis. Locally, the hospital could be designated as an elective care centre and used entirely for day surgery or short-stay surgery (1-3 days). Within a health board area, it may be possible to stream elective care across hospital sites, so that one hospital is designated primarily as an elective care hospital with an ability to deliver a streamlined service uninterrupted by emergency admissions or cancellations across one or several specialties.

57 Streaming also has great potential at regional or national level. Regions of Scotland often have multiple hospitals performing unscheduled and scheduled care; travelling distances for much of the Central Belt are 30 minutes or less to a wide range of hospitals. Regional planning should enable demand across a wider population to be met by streaming hospitals for particular specialties or groups of specialties. This should enable extra capacity to be levered, provided that key staff and patients are willing to travel for a more stable service.

58 Just as we have seen variation in day case rates, so is there variation in operating theatre utilisation. The Audit Commission's report on Operating Theatres (Audit Commission, 2003) suggests that the Bevan Report (1989) standard of 90% theatre session utilisation is still valid. To streamline activity to maximise the use of theatres, the Audit Commission identified 3 main reasons for poorly utilised sessions which should be avoided;

• persistent bottlenecks elsewhere in the hospital, such as lack of ITU beds or general ward beds that were not foreseen when the list was planned
• operations being cancelled because patients were not pre-assessed or because they failed to turn up
• theatre timetables not being updated to reflect changes in workload.

59NHS Boards with hospitals working below 90% theatre session utilisation should implement action plans to address the issue.

60 Action is also required to ensure that all surgical staff meet minimum expectations for surgery time and throughput. Professor John Yates has highlighted a study into the work of 182 orthopaedic surgeons that found they operated for seven hours per week on average (Yates, 2000). A fifth were working below the minimum standard recommended by the British Orthopaedic Association. Professor Yates recommended that all orthopaedic surgeons should be able to operate for a minimum of eight hours per week - four sessions of 3.5 hours or three 5-hour sessions. Theatres are mainly used 09.00-17.00 weekdays, but extending the working day to allow two 5-hour lists would increase capacity by 50%.

61 The recent benchmarking exercise, carried out by ISD Scotland highlighted the variations in length of stay across Scotland and the fact that the number of days a patient spends in hospital prior to an elective operation in Scotland is higher than England.

62 There is evidence to suggest great variation in the pattern of discharge from hospital due to the way the process is managed ( NHS Modernisation Agency, 2004). Waiting for ward rounds that take place at set times, accessing test results or awaiting discharge prescriptions inevitably leads to a variable and unpredictable length of stay.

63 Friday is generally the busiest day for discharges, with limited activity over the weekend. Patients are admitted as emergencies over a 7-day period, but are discharged over five days. Patients admitted on Fridays could potentially have a length of stay 25% longer than those admitted on Tuesdays.

64 This is an area that can be managed effectively, and bottlenecks within the system can be reduced. Effective management brings benefits for patients who have a reduced length of stay and can plan their lives accordingly. There are also significant benefits for patients from remote and rural areas in reduced time away from home and improved co-ordination of transport arrangements.

65 The Centre for Change and Innovation's Unscheduled Care Programme, which launches in May 2005, will work with NHS systems across surgical and medical flows and will look specifically at variations in discharge processes. This element of the programme needs to be given a high priority.

66 As can be seen from the analysis above, we think there is a substantial amount that can be done at the front end of the patient journey. Much of the current emphasis across the NHS is concentrated in this area, but we need to look too at post-operative care.

67 Each year in the UK, 37 million 'follow-up' appointments are made, where patients are asked to return to hospital to have their progress checked, to undergo tests or to get test results. To date, common practice has been to invite patients for a follow-up appointment 'just in case'. If we were to change that practice to one which is based on 'follow-up where there is clinical need', this would undoubtedly reduce the number of appointments. Since 75% or so of outpatient 'Did Not Attends' ( DNAs) are for follow-up appointments, it is clear that some patients are reaching their own view about this issue.

68 Follow-up appointments should take place in the right healthcare setting and be delivered by the appropriate healthcare professional. This means investing in alternatives to the traditional consultant-led, hospital-based appointment. It also means managing the variation that exists between consultants in the numbers of repeat follow-ups they undertake.

69 The first question to be asked should be: 'is a follow-up visit clinically necessary?' If it is, the assumption should be that it is performed in a primary care setting. Automatic hospital-based follow up should be used only where necessary and clinically appropriate. NHS Boards need to actively manage this shift.

70 To illustrate the point, we looked at orthopaedic follow-up. Traditionally, orthopaedic elective patients have attended the hospital for routine follow-up. This is often inconvenient for patients and is costly in terms of consultant and clinic time.

71 With improved pre-operative assessment and preparation, the orthopaedic patient's discharge is now planned prior to admission, thus avoiding delays. Multidisciplinary supported-discharge teams are now established to facilitate prompt return home. Patients do not need to attend hospitals in the early post-operative period. Procedures such as wound checks and removal of sutures can effectively be managed in primary care.

72 Telephone follow-up, either conducted routinely or by providing patients with access to advice should he or she have concerns, avoids unnecessary anxiety or inappropriate GP or hospital visits. Thereafter, arthroplasty follow up can effectively be managed by either nurse or AHP practitioners. Follow-up timing can be arranged in agreement with local guidelines, and follow-up assessment can be conducted according to agreed protocols with validated outcome measures and radiological markers identified.

73 There is no need for patients automatically to see the orthopaedic surgeon. Should progress not be in line with accepted protocols, consultant review will be arranged. In practice, this will involve a small number of patients.

74 With access to required imaging, this service could be provided in primary care settings, decreasing the burden on the acute sector while improving accessibility and convenience for patients.

75 Implementation of the service would also facilitate collection of robust outcome data which is important for clinical governance and monitoring of revision rates.

Summary of recommendations

Lead responsibility: Scottish Executive

• Benchmark performance of NHS Boards (and individual hospitals) in delivering planned care and manage variation firmly and appropriately
• Develop a delivery function that will draw on best practice across the world to further speed up patient access.

Lead responsibility at National Level

• The introduction of Referral Management Services across Scotland
• To treat day surgery as the norm for elective surgery

Lead responsibility at Regional Level

• The development centres/facilities that deal only with elective care either on existing hospital sites or in new buildings

Lead responsibility at Local Level ( CHP)

• Maximise pre-admission services and post-discharge recovery in primary care

B. Diagnostic services

76 Diagnostic services have often been characterised as a 'bottleneck' in the patient's journey of care. Diagnostic services respond to multiple demands from primary care (in cases of direct and open access), screening services, outpatient clinics, Accident and Emergency and inpatient services. They are subject to rapid changes in technology and struggle to keep pace with changing patterns of care.

77 In the past, these services have been unsuccessful in influencing demand in a significant and sustainable way. Despite all efforts, they have been reactive.

78 As in many areas of the NHS, there has been insufficient emphasis on the measurement of demand, activity and capacity or on the application of queuing theory, understanding the importance of flow or addressing fluctuation in demand. Accordingly, there has been a mismatch between activity levels and demand leading to a general perception that diagnostic services lack capacity. There are few examples in Scotland of managed healthcare systems which match clinical developments in referrer services to their impact on the demand for diagnostic services.

79 Three distinct drivers are coming to bear which will have an impact on demand for diagnostic services and the way they are organised and provided.

i) Reducing patient waiting times

• including waiting times for Accident and Emergency treatment and initiation of treatment following a primary care referral
• Fulfilling the Fair to All, Personal to Each ( SEHD, 2004) commitment to develop waiting time standards for key diagnostic services.

ii) Providing local diagnostic services

• The drive to provide as much care as possible locally, including diagnostic services, has implications for where and how diagnostic services are delivered. This imperative is qualified by the need to maximise efficient use of available capacity nationally. While diagnostic tests should be available as locally to the patient as possible, it is crucial for planners to understand that this does not necessarily require that processing and analysis of images or specimens needs to be co-located with testing. Indeed, geographical separation may lead to real efficiencies in the system. The benefits of clinical contact between the referrer and the diagnostic service should not, however, be undervalued.

iii) The changing nature of demand for diagnostic services

• The changing age profile of the population and concomitant epidemiological changes, for example the increased prevalence of such age-related illnesses as cancer and maturity onset diabetes, has led to an inevitable growth in demand for certain diagnostic services.
• There has also been a significant growth in one-stop clinics, where multiple tests are available at one visit. These do not always offer the most efficient use of the diagnostic workforce, but are seen as crucial to the development of patient-centred service design in some settings. It is estimated there are now around 400 such clinics in Scotland.
• The service imperative to roll-out new technologies and procedures as they become available has an impact on diagnostic services. Critical shifts are evident, for example, in the diminishing proportion of plain x-rays compared to 'complex' imaging, including computerised tomography ( CT), magnetic resonance imaging ( MRI) and ultrasound ( US). A significant role shift in who actually performs US image acquisition is well underway. This currently involves training sonographers, who come traditionally from a radiography background. However there is an urgent need to move towards a more inclusive AHP model for sonographer role development as education programmes evolve. Regulatory changes to enable these developments are underway and must be encouraged. In Pathology and Laboratory Medicine, continuing rapid advances in automation mean that consideration should be given to the rationalisation of some non-acute routine and screening functions. There are, of course, many benefits arising from new technologies and investigative modalities. The imperative is to have these not only more widely available, but also more accessible to patients.
• Imaging and laboratory tests are playing an ever greater role in accurate diagnosis. As testing is refined and, with improved user knowledge, skill and experience, becomes more diagnostically focused, this means that there is increased pressure on services. As technology advances, there is not only an opportunity to provide diagnostic services more effectively in traditional settings, but also to develop new investigation pathways that add value in additional areas of clinical practice.

Redesigning services

80 The NHS Modernisation Agency's report, 10 High-Impact Changes for Service Improvement and Delivery ( NHS Modernisation Agency, 2004) is a valuable introduction to some of the main redesign concepts. It states:

'We tend to think that diagnostic bottlenecks are caused by a lack of capacity. In fact, they are often caused by the mismatch in the variation in demand and the variation in supply. Systematic application of some basic redesign tools to match capacity and demand can have a dramatic effect on the "flow" of patients through the system.'

81 A proactively planned and managed system of matching capacity to demand and a better understanding of the key constraints on local capacity (human and technological) is an imperative for the future. Demand management needs to be the responsibility of the supplier service in partnership with referral services. The control of demand needs to be determined by clear and accessible written (electronically embedded) guidance and decision support. An example of such guidance would be the RCR/ EU referral guidelines for prescribers of ionising radiation. This would be most effective if available electronically at the time of request.

82 Evidence suggests that the pattern of demand for a diagnostic service can be significantly improved (inappropriate demand reduced, appropriate demand increased) by targeting referrers with a variety of techniques. While there are no 'magic bullets', audit and feedback combined with condition-specific prompts are effective. Diagnostic services will become a uniformly 'enabling' aspect of the service when all demands are understood and, where appropriate, managed.

83 In any given diagnostic service, capacity is limited by the key constraint, such as the availability of given equipment or of a key professional. Activity is not the same as capacity. Activity measures what is done, not what is theoretically capable of being done when set to the key constraint. Redesign has an important role to play in identifying bottlenecks in processes and duplication or secondary constraints which fail to achieve best use of capacity.

84 Experience of redesigning services in Scotland provides some general principles to guide future diagnostic service redesign efforts:

• Waiting list initiatives are a useful means by which to remove historical backlogs, but must support redesign rather than take its place. Without redesign, backlogs will quickly reappear. Waiting list initiatives should be seen as short-term fixes which do not address the underlying problem. It is analysis of the underlying problem which is the key to successful redesign. Waiting list initiatives should be co-ordinated with performance management so that poor performance is not rewarded with additional resources.
• Unscheduled and elective work should be disengaged wherever possible to protect capacity in both.
• If at all possible, 9 to 5 activity should be optimised and the working day extended before resorting to the acquisition of additional equipment. Services should work smarter by, for instance, staggering lunch hours and start and finish times to maximise throughput. Rigorous forward planning of leave and other predictable absence is essential.
• Audit and performance management driven by effective data collection using agreed definitions should be carried out.
• Clinical leaders with sufficient time, vision and focus should be engaged to drive reform. Any short-term loss of capacity is more than compensated by the potentially huge long-term gains.
• Interfaces between primary care, secondary care and Managed Clinical Networks should be reduced. James Paget Hospital in Norfolk reduced treatment time for lung cancer by allowing direct referral from radiologist to physician, rather than radiologist to GP to physician. The breakdown of these types of artificial barrier is central to providing patient-centred care.

85 We looked in detail at two sets of diagnostic services: imaging, and pathology.

Imaging

86 Diagnostic imaging services are widely viewed as a bottleneck in patient flow. This is often attributed to a significant shortfall in radiographer and radiologist workforce or a perceived lack of equipment, but also reflects unprecedented levels of demand.

87 The increase in demand for imaging services is a consequence of technological development and maturity; the changing nature of clinical management (particularly the expanded role of cross-sectional imaging in cancer) and higher patient expectations. Greater public awareness of and interest in health has generated a better-informed population that knows what could and should be available.

88 We have identified 5 key challenges for imaging:

• workforce,
• information,
• digital imaging,
• service configuration,
• remote and rural provision.

89 The growing demand for diagnostic services will require careful planning to meet future needs. However it is recognised that there are significant challenges to be met in providing a sustainable workforce for existing service capacity. Shortages of key groups of imaging professionals, including radiologists, radiographers and sonographers, are widely recognised as a limiting factor for expansion of services in Scotland, the UK, and the international radiological community.

90 A survey of the vacant consultant radiologist posts in Scotland in January 2005 by the Scottish Standing Committee of the Royal College of Radiologists put the vacancy rate at 49.4 posts, or 17.7% of all established posts. It is clear that more radiologists and radiographers are required, but we need to re-profile the workforce as well as train more people.

91NHS Scotland must move towards providing imaging services when they are needed. This
will involve greater flexibility in working patterns including promotion of the extended working day. While the move to flexible or less than full-time working is to some extent inevitable, it should be underpinned by recognition of the needs of patients and the imperative of providing a core service.

92 The following steps should be taken to support the re-profiling of the diagnostic imaging workforce skill set to meet the needs of the service:

• provision of an education framework sharing common multi-professional competency standards.
• development of assistant practitioner standards which meet anticipated 2007 national registration standards.
• national definition and accreditation of new roles within diagnostic services.
• maximisation of unique core skills and competencies.
• accurate service and training needs analyses to ensure that individual and multi-professional skill sets meet patient needs.
• career pathways that seek to retain skilled and experienced clinical practitioners within frontline diagnostic services.
• assurance that members of the team are skilled and competent to perform their functions, supported by appropriate training and clinical governance.

93 An adequate Radiology Information System with nationwide coverage and agreed definitions and application should be a priority. The system could serve as a clinical governance tool but, if comprehensively and rigorously populated, would also provide a sound basis for service management, delivery, planning and modernisation.

94NHS Scotland has been providing pump-priming funds for one particular Radiology Data Collection system, CiRiS. The ability to opt in and out of CiRiS has meant incomplete coverage across NHS Scotland, with at least one large area opting out (until recently). The data set is therefore incomplete, reducing benefits in terms of availability of comparable data, benchmarking, and transferable lessons.

95 Although feedback from the CiRiS system to the service has been slow to materialise, information recently available provides a valuable insight into the staff and service. For example, approximately 47% of plain radiography is provided outwith 'normal' working hours thus reinforcing the desirability of a 24/7 service.

96 Mandatory use of CiRiS appears to be the best option available to NHS Scotland in the short term. In the longer term, a single, national, clinical information system for all specialties should be the goal for the service.

97 Digital imaging will be at the heart of clinical services in future. A Picture Archiving and Communication System ( PACS) captures, stores and displays digital images such as digital radiology images, x-rays or scans, removing the need to print images and store them manually. MRI or CT scans create large data sets where there can be 1000 images for a routine study. Not only is PACS an efficient tool to acquire and store images, but it also allows flexibility in display, adding diagnostic value to surgeons in particular.

98 The national Scottish PACS procurement is now at an advanced stage. It is essential that PACS is rolled out quickly to all parts of Scotland. Individual NHS Boards must be made aware of the priority placed on this by NHS Scotland.

99 The real clinical benefits will come when PACS is linked to a single CHI-based care record; a radiology information system and a robust mature voice-recognition software. It is critical that PACS roll-out is linked to equipment replacement and digitisation. This will require a well-resourced, centrally-supported project management team. It is clear that under-resourced project management could entail a huge additional cost burden in terms of wasted investment or delayed realisation of potential efficiencies.

100 There is great scope in NHS Scotland, facilitated by the application of the technologies described above, to reconfigure imaging services by separating image acquisition ( e.g. scanning a patient) from analysis and reporting. Accordingly, the patient and the reporter (the person carrying out the analysis and reporting: usually, but not necessarily, a radiologist) do not need to be in the same place. The patient can thus avoid travel to a specialist centre for some tests: this being determined by the local availability of equipment rather than of reporters. As such, there is potential to provide more diagnostics in local settings if justified in terms of overall capacity. This is a shift which should be encouraged.

101 The radiological reporting process is subject to many interruptions, which create discontinuity of thought with consequent impacts on patient safety. Reporters need to be focused on an individual patient's images. Working practices should reflect the need for a controlled reporting environment and limited multi-tasking. There are occasions when clinicians find added value in discussing cases with the radiologist who has reported examinations, and there is no reason why this could not be facilitated if robust systems are put in place.

102 This development could help maintain or develop services in remote and rural areas. PACS and CHI-based tele-technologies must be developed to enhance the potential for geographical separation of image acquisition and reporting.

103 Tele-assessment underpins much of the desired objective in unscheduled care of providing care locally and avoiding unnecessary referral to tertiary centres. This opens up the possibility of a centrally co-ordinated radiologist on-call service for imaging. It is recommended that the feasibility of such a service be assessed. In the longer term, there is potential for Accident and Emergency reporting to be performed in and out of normal working hours by this method.

104 Scotland's dispersed population presents specific challenges for the provision of fair and equitable access to diagnostic services in remote and rural areas. In addressing these issues, the aim should be to provide safe patient focused care while acknowledging the important operational issues relating to economies of scale, logistics and clinical governance.

105 The level of imaging required to support a general clinical service has moved on greatly in the last two decades. It is no longer acceptable to provide imaging services to a District General Hospital ( DGH) without ready access to ultrasound, CT and, increasingly, MRI, in addition to plain radiography.

106 Most District General Hospitals in Scotland had up-to-date ultrasound equipment and CT scanners at the last national survey, and the majority had access to nuclear medicine and MRI. Some DGHs provide excellent vascular and interventional services: this should be dictated by local expertise and volume of local clinical activity and be subject to clinical governance. As a general principle, however, low-volume, highly-specialised equipment and techniques should be sited within specialist centres.

107 Most DGHs provide emergency neuro-imaging and have some form of tele-radiology link with specialist neurosurgical centres. These links, however, are often far from robust. Some have been forged by the enthusiasm of the local clinical team with little managerial or financial support.

108 In a country such as Scotland, which has a dispersed population, there should be formal recognition of tele-radiology and tele-conferencing services. Quality assurance systems must be developed and maintained around working practice and skills maintenance. Tele-radiology links require to be strengthened not just for neuro-imaging, but for all services, including oncology, surgery and emergency support.

109 Tele-radiology linkage should be an obligatory part of healthcare provision in tertiary centres. Currently, the responsibility for the tele-radiology link falls to the DGH as the referring centre, and there is little incentive for the receiving tertiary centre to facilitate, support or fund the link. This obstacle will not be resolved until acceptance and support of tele-radiology is a mandatory requirement for both DGHs and tertiary centres. Regional planning mechanisms should ensure adequate bi-/multi-partite support for such services.

110 There should also be integration of tele-radiology links with other tele-medicine initiatives, including the facility to offer education by broadcast and other innovative media. Managed Clinical Networks will be helpful vehicles for this and must be integrated with Managed Diagnostic Networks.

Pathology and Laboratory Medicine

111 Pathology and Laboratory Medicine includes the following main specialties:

• Clinical Biochemistry
• Cytopathology
• Genetics
• Haematology
• Histopathology
• Immunology
• Medical Microbiology
• Transfusion Medicine
• Virology.

Many of these specialties include one or more sub-specialties.

112 There are Pathology and Laboratory Medicine departments in every acute hospital in Scotland, although not every specialty is represented in each.

113 It is generally accepted that 60-70% of diagnoses rely on output from these services. The workload is rising across all specialties. In Clinical Biochemistry, for example, the national workload has doubled in less than ten years. The highest annual increase occurred in 2004, due in large measure to a rise of almost 20% from the primary care sector.

114 There are several drivers for this increased workload including:

• greater clinical activity
• changing clinical practice, including a shift from secondary to primary care
• an ageing population
• greater public awareness of health issues
• public health issues, including healthcare acquired infection
• evidence-based clinical guidelines (Scottish Intercollegiate Guidelines Network ( SIGN), National Institute for Clinical Excellence ( NICE) etc)
• expansion of cancer screening programmes
• the new Consultant and General Medical Services ( GMS) contracts
• government targets
• the availability of new services (especially molecular diagnostics).

115 The rise in laboratory workload has not been matched by a rise in resources because laboratories have commonly been viewed as a cost centre. Staffing budgets have remained largely static in real terms during this rapid growth phase, and budgets have failed to take full account of increased demands. As a result, there has been pressure to reduce staffing levels, despite the rapid increase in workload, to meet overall financial targets.

116 As with all diagnostic specialties, modern information technology and management is crucial to Pathology and Laboratory Medicine. Many laboratory information and management systems contain very large databases of patient information that need to be interrogated, updated and communicated on a 24/7 basis. Lack of investment means there is often incompatibility between laboratory systems in the same hospital and serious deficiencies in connectivity between laboratory, hospital and community information and management systems.

117 Pathology and Laboratory Medicine services vary in the urgency with which results are required, which influences the need for locally available services at the point of contact. Core Clinical Biochemistry, Haematology and Blood Transfusion services are required to deliver a turnaround time of less than:

• one hour for urgent requests for areas such as Accident & Emergency departments, intensive therapy units, acute medical receiving units and obstetric services
• four hours for standard requests such as those from inpatients departments
• 24 hours for other non-specialist requests, including outpatients departments and primary care.

This means that 24/7 on-site services are essential in each acute hospital.

118 There is a need to develop a strategy for the modernisation of Pathology and Laboratory Medicine. The strategy should have the following key elements:

• reconfiguration of the service
• Managed Clinical Networks
• performance management
• new technology
• service redesign.

119 Currently, the configuration of Pathology and Laboratory Medicine services in Scotland is very variable and owes much to history. For example, some NHS Boards have sizeable DGHs without an on-site pathology department, while others provide a more dispersed pathology service across all DGH sites. It is recognised that there is not a single model of laboratory service configuration which will suit all areas of Scotland.

120 It is logical and highly desirable that laboratory services be aligned with the clinical services they support. This will facilitate relevant and efficient laboratory services and the inclusion of the laboratory specialist as a member of the multidisciplinary team. The future configuration of Pathology and Laboratory Medicine services will therefore depend on changes to and developments in clinical services.

121 Interaction of disease-specific and laboratory Managed Clinical Networks will be crucial in managing this process. Different models will apply according to the clinical service and other factors, including population demographics and geography. For example:

• On-site core Clinical Biochemistry, Haematology and Transfusion services will be required in all acute medical hospital settings, with the availability of 24/7 results within a clinically acceptable turnaround time
• locally-available services will be required for Pathology, Immunology, Microbiology and Virology, but not necessarily on every acute site
• specialist Pathology and Laboratory Medicine services should be tailored to meet the needs of regional and national Managed Clinical Networks in areas such as cancer, cardiovascular disease and transplantation
• highly-specialist Pathology and Laboratory Medicine services are best provided through managed national provision from one or more centres; the Scottish Molecular Genetics Consortium is the best current example.

122 A Managed Clinical Network in Histopathology/Cytopathology is being implemented. This has been set up through the Regional Planning Groups and the Scottish Cancer Group and should be viewed as the start of a more extensive programme of modernisation. The network will function as a model for other potential Managed Diagnostic Networks.

123 It seems likely that there will be an expansion of regional and national Managed Clinical Networks in Scotland. It is also possible that Managed Diagnostic Networks could develop to support some areas of clinical practice. The active involvement of laboratory medicine specialists as team members of multidisciplinary Managed Clinical Networks and future Managed Diagnostic Networks is to be commended as good practice. It will ensure:

• the delivery of effective, targeted laboratory services
• optimal use of laboratory services by clinical users
• the implementation of evidence-based guidelines
• the organisation and development of specialist services and a sharing of resources at regional and national level
• co-ordination of diagnostic services in targeted applications
• multidisciplinary and multi-centre clinical audit and research.

124 Workload management and requesting behaviour can be influenced through the provision of evidence-based support material, which can help to ensure realistic use of available resources. A project in Grampian and Moray, for example, demonstrated that the combination of test report reminders and enhanced educational feedback reduced requesting from the primary care sector by 16.8%, resulting in a reduction in consumable budget of £130,000 per annum. This approach is being further developed in England through the Good Practice in Primary Care project, which has the support of all relevant stakeholders. Successful workload management requires, however, considerable investment in ICT and consultant laboratory specialists' time if it is to be maintained.

125 Information and Communications Technology ( ICT) and information management are central to the accurate and effective use of Pathology and Laboratory information services and have much to contribute to improved turnaround time, reduction in waiting times and reduction in the transmission of infections.

126 The state of ICT in Scottish laboratories is variable but is generally well below that required for a modern, efficient service. There is an urgent need for ICT and information management systems that will allow seamless connectivity across laboratory specialties, with other diagnostic services, and with hospital and community-based information systems. The introduction of the unique patient identifier ( CHI) will facilitate this process. Increased use of voice recognition technology will speed up the production of pathology reports and so facilitate the on-line authorisation already widely used in laboratory medicine.

127 In considering the scope for service redesign, Pathology and Laboratory Medicine departments should focus on ways of using available resources better. The introduction of an extended working day in appropriate laboratory settings, for example, will enable better use of expensive equipment and automated analytical platforms. Extended working will also allow work from primary care to be processed to make results available when primary care centres are open.

128 The Pathology and Laboratory Medicine MDNs should take on the role of gathering and communicating good practice information on service redesign and new ways of working in laboratory services in Scotland. Advising the workforce development and planning aspects of new ways of working should be part of this role.

129 A full list of recommendations from the Diagnostic Services Action Team can be found in its full Report at http://www.show.scot.nhs.uk/sehd/nationalframework

Those recommendations are endorsed in full, but can be summarised as:

Organisation

• Develop a Regional and National overview of diagnostic services within the framework of the Regional Planning Groups.
• Develop Managed Diagnostic Networks based on the existing Scottish Pathology Network, linked to Managed Clinical Networks.
• Develop and support clinical leadership.

Capacity, demand and redesign

• Balance capacity and demand. Expand capacity by using redesign to eliminate rate-limiting steps and manage demand using decision-support and referral protocols wherever possible.
• Use waiting list initiatives to remove backlogs only in support of redesign.
• Benchmark and monitor performance utilising robust electronic data collection, ideally linked to departmental information systems to minimise manual entry.
• Agree data definitions and enforce nationally.
• Disengage acute from elective work wherever possible.
• Promote local access wherever possible as determined by overall service capacity.
• Utilising technology, disengage interpretation from point of image capture/testing to improve local access and overall quality of care.
• Centralise highly-specialised services to improve overall access on a 24/7 basis.
• Reduce interfaces between primary, secondary and tertiary care.

Workforce

• Promote recruitment and retention by encouraging flexibility in the workforce and by enhancing the roles of non-medical professionals.
• Plan to backfill for staff up-skilling.
• Increase recruitment into undergraduate programmes and improve careers management.

Technology

• Accelerate the National use of CHI as the unique identifier.
• Develop a national strategy for Electronic Care Record implementation supported by adequate resource and project management.
• Develop electronic systems for decision support embedded in referral protocols.
• Accelerate the National PACS roll out/tele-medicine network, voice recognition implementation and co-ordinate with equipment replacement.
• Make CiRiS mandatory (radiology) and interface with RIS systems if possible.

References

Audit Commission (2003) Operating Theatres Review of National Findings
www.audit-commission.gov.uk

Audit Scotland (2004) Day surgery in Scotland - reviewing progress. April 2004 http://www.audit-scotland.gov.uk/publications/pdf/2004/04pf04ag.pdf

Audit Scotland (2004) An Overview of the performance of the NHS In Scotland
www.audit-scotland.gov.uk

Hurst,J. Siciliani,L. (2003) Tackling Excessive Waiting Times for Elective Surgery A Comparison of Policies in Twelve OECD Countries,OECDwww.oecd.org

Modernisation Agency 10 High Impact Changes for Service Improvement and Deliverywww.modern.nhs.uk

Scottish Executive Health Department (2003) Partnership for Care Edinburgh SEHD

Scottish Executive Health Department (2004) Fair to All Personal to Each Edinburgh SEHD

The Bevan Report(1989)

Yates,J. Harley,M. Jayes,Bob. (2000) Blade Runners, Health Service Journal pp 20-23

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