02 Activity
Activity reflects the actual number of patients being seen by consultants (or other professionals) in clinics. The data is widely collected and reported by ISD. Activity is not capacity, though it is often described as such.
The importance of measuring activity lies in variation. Variation in activity occurs for a number of reasons including:
- Staff absence;
- Clinic cancellation;
- Patient failure to attend.
A large amount of variation in activity will contribute to a queue (waiting list) developing.
The Outpatient Programme encouraged people to measure activity in order to better understand the queue and to evaluate their use of available capacity.
One major stream of work looked at reducing variation at clinic level, through the introduction of Patient Focussed Booking ( PFB). PFB reduces variation in activity by reducing hospital clinic cancellation and patient DNA rates. It also has a positive impact upon queue management (mentioned later in this document) and has the obvious advantage of introducing choice for patients.
PFB projects were run by 13 of the Health Boards to offer patients greater choice in booking appointments and to improve clinic efficency. Patients are advised of the probable wait for their outpatient appointment and are then contacted six weeks prior to this date and invited to call the hospital. The patient then calls and can be offered appointments that are available over the next six weeks. Patients are able to choose appointments that are more suitable to them and so consequently are more likely to attend.
Through the PFB process patients are only booked into clinics that occur up to six weeks in advance. With a strict six-week hospital cancellation policy, patients are not affected by clinics or appointments being moved or cancelled.
- In NHS Grampian, the hospital cancellation rate fell from 6% in September 2003 to 2% in September 2005.
- In May 2004, the DNA rate for new dermatology patients in NHS Tayside stood at 14%. 12 months later, the rate recorded for patients who had been through the PFB process was only 3.5%.
- NHS Lanarkshire experienced a 10% removal rate in general medicine at the six-week validation point. Without PFB these patients would not have been identified at this stage and would have been likely to DNA.
- As the graph below demonstrates, the number of patients affected by hospital cancellations in NHS Argyll and Clyde has halved since PFB was introduced.
Graph 1: Impact of PFB on cancellation rates in NHS Argyll and Clyde
- The graph overleaf demonstrates the impact of PFB at Yorkhill Hospital on DNA rates. Note the green and red lines which demonstrate the difference between those patients booked using PFB and those who were not.
Graph 2: Impact of PFB on Did Not Attend rates at Yorkhill Hospital
- Six NHS Boards developed the IT capability to include PFB for patients returning for a further appointment. The effects on DNA and cancellation rates have been very similar to those experienced with new patients. We estimate that 200,000 return appointments are currently going through the PFB process per annum.
Graph 3: Impact of PFB on return patient DNA rates, Yorkhill and Dumfries & Galloway
Learning Point
"One reason for short-notice cancellation by junior doctor staff is that leave is applied for in another department or hospital and staff arrive in a new department with pre-approved leave. All orientation and induction material sent to new staff should include details of the six-week notification of leave policy." - A Guide to Good Practice (2005), "National Leadership and Innovation Agency for Healthcare".
Programme Action
As well as providing resource for project management and measurement of projects such as those described above, the Outpatient Programme:
- Produced a Patient Focussed Booking update document and distributed this across Scotland;
- Supported a PFB project managers' group for problem solving and spreading good practice;
- In collaboration with PFB project managers produced a Guide to Implementation to inform future work.
Programme Learning Points
- The effectiveness of IT and telephone systems have a direct impact on PFB;
- Senior managerial and clinical support is required throughout PFB implementation to drive the process change;
- PFB is most successful where clinic cancellation and patient non-attendance policies are in place and robustly applied;
- There are circumstances where PFB may need to be adapted, e.g. where waiting times are less than six weeks or clinics are arranged with less than six weeks' notice. Also, circumstances where very specific appointments dates/times need to be arranged. For example obstetrics or where multiple appointments with set times are needed (ophthalmology). In addition, every effort must be made to ensure that specific patient groups, e.g. those with communication needs, are accommodated and receive the same choice as other groups.