A PRACTICAL EXAMPLE OF A PRACTICAL EXAMPLE OF DCAQDCAQ

Dr Gerry BeattieDr Gerry BeattieClinical Lead, NHS LothianClinical Lead, NHS Lothian

1818thth November, 2009 November, 2009

DCAQ Gynaecology - DCAQ Gynaecology - backgroundbackground• Why is the out-patient waiting time Why is the out-patient waiting time

16-18 weeks ?16-18 weeks ?• What are the consultant staff doing ?What are the consultant staff doing ?• Why are we losing capacity and how Why are we losing capacity and how

can we stop it ?can we stop it ?• What are we going to do about the What are we going to do about the

next round of job planning ? next round of job planning ?

DCAQ Gynaecology DCAQ Gynaecology • UNDELIVIERED ACTIVITY – the waiting list, UNDELIVIERED ACTIVITY – the waiting list,

service entry points, primary care interface.service entry points, primary care interface.

• DELIVERED ACTIVITY – productivity, rotas, DELIVERED ACTIVITY – productivity, rotas, inappropriate activity, templates.inappropriate activity, templates.

• LOST CAPACITY – leave, compensatory rest, LOST CAPACITY – leave, compensatory rest, short notice cancellationsshort notice cancellations

DCAQ GynaecologyDCAQ Gynaecology• DEMANDDEMAND

• CAPACITYCAPACITY

• ACTIVITYACTIVITY

• QUEUESQUEUES

Two important points to Two important points to remember remember

• It’s just good housekeeping, it’s not It’s just good housekeeping, it’s not rocket science !rocket science !

• Just because ‘it’s aye been done this Just because ‘it’s aye been done this way’ doesn’t mean there isn’t a way’ doesn’t mean there isn’t a better way of doing it !better way of doing it !

Demand – the problemsDemand – the problems• Unclear as to what the demand was in Unclear as to what the demand was in

terms of numbersterms of numbers• No idea as to the case mix out thereNo idea as to the case mix out there• 6 entry points into the system – NRIE, 6 entry points into the system – NRIE,

WGH, SJH, LCTC, Roodlands, Liberton.WGH, SJH, LCTC, Roodlands, Liberton.• Little dialogue between primary care Little dialogue between primary care

and the acute sectorand the acute sector

Demand – some solutionsDemand – some solutions• Centralised Booking set up for Lothian – Centralised Booking set up for Lothian –

bringing all referrals to one central point in the bringing all referrals to one central point in the NRIE and now moving to e referral and e-triageNRIE and now moving to e referral and e-triage

• Outcoming from triage recorded to inform the Outcoming from triage recorded to inform the size and location of service queues and what size and location of service queues and what needs to be in place whereneeds to be in place where

• Exploring electronic GP helplines to prevent Exploring electronic GP helplines to prevent patients becoming referralspatients becoming referrals

Another important point -Another important point -

• Demand is not a given, it can be Demand is not a given, it can be influenced in your favourinfluenced in your favour

• The 3 D’s – Driving Down Demand !The 3 D’s – Driving Down Demand !

A thought -A thought -• What if referrals were not referrals What if referrals were not referrals

and simply requests for advice ?and simply requests for advice ?

Capacity – the problemsCapacity – the problems• Difficult to defineDifficult to define

• Difficult to measureDifficult to measure

• Lost capacityLost capacity

• Reliant on Consultant job plansReliant on Consultant job plans

What is capacity ?What is capacity ?

• Templated capacity (52 weeks)Templated capacity (52 weeks)

• Adjusted capacity (42 weeks)Adjusted capacity (42 weeks)

• Delivered capacity (about 36 weeks)Delivered capacity (about 36 weeks)

What is capacity ?What is capacity ?

• Capacity is a dynamic concept that is Capacity is a dynamic concept that is constantly changingconstantly changing

• It is not a straight line or a box with It is not a straight line or a box with rigid sidesrigid sides

Capacity ModellingCapacity Modelling• Real time job plans can help measure Real time job plans can help measure

capacitycapacity• Convert weekly job plans into at least Convert weekly job plans into at least

4 weekly spreadsheets to overview 4 weekly spreadsheets to overview capacity and identify peaks and capacity and identify peaks and troughstroughs

• A real need for dynamic prospective A real need for dynamic prospective capacity modellingcapacity modelling

Capacity – some solutionsCapacity – some solutions• Centralised booking has allowed Centralised booking has allowed

capacity measurement across Lothian capacity measurement across Lothian and respond to service pressuresand respond to service pressures

• Real time job plan mappingReal time job plan mapping• Sanitisation of clinic templatesSanitisation of clinic templates• Standardisation of clinic templatesStandardisation of clinic templates• Flexibility of consultant workforceFlexibility of consultant workforce

Activity – the problemsActivity – the problems• Lots of it –but not accurately recordedLots of it –but not accurately recorded• Coding issuesCoding issues• Inappropriate activityInappropriate activity• Clinic templates – new/return ratiosClinic templates – new/return ratios• Outreach clinicsOutreach clinics• Consultant productivityConsultant productivity• Role of senior traineesRole of senior trainees

Activity – some solutionsActivity – some solutions• Accurate recording and coding, with Accurate recording and coding, with

medical input into codingmedical input into coding• Minimum standards for clinic templatesMinimum standards for clinic templates• New/return ratios revised in the light of New/return ratios revised in the light of

speciality developmentspeciality development• The ring pessary challengeThe ring pessary challenge• Utilisation of senior traineesUtilisation of senior trainees• Keep the mavericks in the buildingKeep the mavericks in the building

Queues – the problemsQueues – the problems

• There was a big one and lots of little There was a big one and lots of little onesones

• There was no idea of how wide the There was no idea of how wide the pathway had to be to accommodate the pathway had to be to accommodate the queuesqueues

• Chaos reigned !Chaos reigned !

Queues – some solutionsQueues – some solutions• Centralised booking has streamlined, Centralised booking has streamlined,

quantified and reduced the queuesquantified and reduced the queues

• Patients now seen by the most appropriate Patients now seen by the most appropriate clinician at the most appropriate siteclinician at the most appropriate site

• Waiting time across Lothian now 6 weeks Waiting time across Lothian now 6 weeks and falling !and falling !

• Question - DCAQ – where did we start Question - DCAQ – where did we start ??

• Answer - Job planningAnswer - Job planning

The 2004 Consultant The 2004 Consultant ContractContract• Full time commitment of 10 programmed Full time commitment of 10 programmed

activities (PAs) per week – 4 hour sessionsactivities (PAs) per week – 4 hour sessions• Direct clinical care (DCC), Supporting Direct clinical care (DCC), Supporting

professional activities (SPA), professional activities (SPA), additional/external dutiesadditional/external duties

• 7.5 PAs DCC / 2.5 PAs SPA (Plans for 9+1)7.5 PAs DCC / 2.5 PAs SPA (Plans for 9+1)• Flexibility depending on commitments eg Flexibility depending on commitments eg

Clinical Governance leads etcClinical Governance leads etc• EPAs – separate contract, no obligationEPAs – separate contract, no obligation

Job PlanningJob Planning• The process is individual but The process is individual but

collectively job plans must reflect the collectively job plans must reflect the over all needs of the serviceover all needs of the service

• Provides the capacity to meet the Provides the capacity to meet the demand on the servicedemand on the service

Job planning – the issuesJob planning – the issues• Plan the service to meet the demandPlan the service to meet the demand• Consultant productivity – 42 wks – if Consultant productivity – 42 wks – if

not, why not ?not, why not ?• Notify, control, monitor and restrict Notify, control, monitor and restrict

leave – and learn to say NO !leave – and learn to say NO !• Get service into PAs and use EPAs for Get service into PAs and use EPAs for

reward – eg cross cover / additional reward – eg cross cover / additional activity activity

Job planning – the issuesJob planning – the issues• Rota management to reduce impact Rota management to reduce impact

of compensatory rest – lost capacityof compensatory rest – lost capacity• Allow flexibility in the job planning Allow flexibility in the job planning

processprocess• Play to individual strengthsPlay to individual strengths• Need all consultants look the same ?Need all consultants look the same ?

Consultant engagementConsultant engagement• Protected time gives recognition to Protected time gives recognition to

the importance of the workthe importance of the work

• Sell the carrot, not the stickSell the carrot, not the stick

• Get one of their own doing the workGet one of their own doing the work

A disease analogyA disease analogy

• Symptoms of reluctance to change, Symptoms of reluctance to change, reluctance to engage and inefficiencyreluctance to engage and inefficiency

• Syndrome of ‘ we’ve aye done it this Syndrome of ‘ we’ve aye done it this way’way’

The challenge - The challenge -

Physicians of the utmost famePhysicians of the utmost fameWere called at once, but when they cameWere called at once, but when they cameThey muttered as they took their feesThey muttered as they took their feesThere is no cure for this disease There is no cure for this disease

Hilaire BellocHilaire Belloc

Any questions ?Any questions ?