the biggest thing since Körner

Brian DerryASSIST Vice Chair

Director of Informatics The Leeds Teaching Hospitals NHS Trust

brian.derry@leedsth.nhs.uk

Tactical and strategic informatics challenges of 18 weeks – an acute

Trust perspective…

or…

Outline

1. Where are we now?

2. Where do we need to get to?

3. Informatics issues

4. Conclusions

Where are we now?

…I really wouldn’t start from here…

Current access targets

Now Mar 07 Mar 08

• Outpatients 13w 11w 5w

• Inpatients 26w 20w 11w

• “Diagnostics” 26w 13w 6w

• Cancer 14/31/62 days

Stocks at month end only – except Cancer

STOP PRESS

LDPs 18 weeks for

Admitted patients 85% tolerance

Non-admitted patients 90% tolerance

By March 2008!!!!!!!

Breaches - IP & OP

0

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Changed to 6/13 targets

IP

OP

Waiting times target coverage

GP ref OP att consDecisionTo admit

Admit & treat Home

Other ref 1st att2nd+ atts

Admit & cancel

OP att nurse

DecisionTo admit

Any primary care

2nd+ atts

X

X

XX

X X

LTHT Outpatient Attendances 2005/6

GP-Cons 1st13%

GP-Cons 2nd+26%

Other-Con 2nd+41%

Other-Cons 1st8%

Other-NonCons 1st1%

Other-NonCons 2nd+6%GP-NonCons 2nd+

4%

GP-NonCons 1st1%

Where do we need to get to?

…to boldly go…

NHS Plan

“By December 2008 no one

will have to wait longer than 18 weeks

from GP referral

to hospital treatment”

Principles

• Patient experience – no hidden waits

• Simplicity, clarity & transparency

• Consistency with NHS Plan pledge

• Reinforcing positive behaviours in providers & commissioners

• Resilience – future proof in patient-led NHS with more Choice & plurality

• Data burden on NHS

Definitions…

Key issues

Clock starts? Clock stops?

Scope – services, patients?

OP & diagnostics

IP

Measurement & audit?

Scope: includes -1

• Referrals from: – consultants to consultants - agreed by “1o care”, unless “urgent”!– GPSIs– General Dental Practitioners– Optometrists – A&E, Minor Injuries Unit, Walk-in-centre– GUM– National screening programmes– Other primary care profs - when PCTs choose!– “mechanisms locally”

• Referrals to consultants working in community (incl. employed by PCT)

• Endoscopies - OP or DC!

“…from GP referral to hospital treatment”

Scope: includes -2

Clinically complex cases, including tertiary referrals, Choice & multi-org pathways:

• No suspensions

• No reset for provider cancellations

• % tolerance

• …..audit? “By December 2008 no one will have to wait longer than 18 weeks..”

Scope: excludes - 1

• Direct access: – Diagnostics pre-decision to refer– Physiotherapy– Occupational Therapy– Speech & language Therapy

• Podiatry & Audiology if not consultant-led

• Referrals to nurse consultants & AHPs

Clock start -1

• At point of booking (no re-start if wrong clinic) • Intermediate services (CAS, GPSIs, RMS) – at

GP ref if part of 2o pathway, not of 1o

• Direct access diagnostics (1o&2o) – when patient books 2o OP appointment

• If planned sequence, new pathway when medically fit for each stage

• Patient choose “late” appointments – undecided?

Clock stops -1• Start treatment – “1st curative/definitive

treatment”?! (not admission for diagnostics )

• Admission & treatment as IP/DC (not cancelled ops)

• OP (incl AHP) – procedure

• Return to 1o care after OP/diagnostics & no further 2o care action

• Medical device fitted

Clock stops -2• Patient declines treatment or dies• “Watchful waiting/active monitoring” starts• DNAs

– 1@1st appointment & back to GP….but CAB– @ follow-up ….in tolerance

• Other patient-initiated delays (e.g. repeated failures to agree date …but ?“reasonable offers”) - in tolerance

• When in doubt: “will be rules” or in tolerance!

Average waits by consultant: General Surgery, LTHT, March 2006

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

We

ek

s

IP component

OP component

18

Average waits by consultant: T&O, LTHT, March 2006

-

20.0

40.0

60.0

80.0

100.0

120.0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Wee

ks

IP component

OP component

18

Inpatient waiting list reductions - main surgical specialties

NHS Yorkshire and the Humber

5,3007,500

4,250 4,900

16,500

9,900

0

5,000

10,000

15,000

20,000

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Service Implications

• Clearing the ‘backlog’

• Booking & scheduling pathways

• Patient flows – 1o, ISTC, 2o , 3o , 4o

• Pathway management

• Capacity planning & management

• Transition & parallel running

• Clinical engagement

Informatics issues

…just a few…

Information issues

• Clinician recording – OP outcomes, intentions, 1st curative treatment…

• Patient admin processes & recording

• Integrating information along pathways

• Pathway identification & linkage

• NHS data model

• PAS, diagnostics & other systems

Data model

Organisation

Staff group

Setting

Administrative

Process

Patient

Clinical

Outcome

Shifting the focus from

Systems: current PAS context

• Central returns/admin - centric: – Retrospective & paper-driven– Consultant orientated– Care setting insularity….

• 1990s front-ends, 1980s thinking, & 1970s data & business model

Systems requirements

• Patient-centred & pathway oriented • Pro-active scheduling & booking• Integrating “OP”, Diagnostics & “IP” • Cumulative PTLs• Link information across organisations &

professional groups

• By mid 2007 at the latest!

Reducing the burden

Monthly:

By PCT

Stocks

Flows: OP/IP

= 300 returns/month

Accountability

Supporting delivery X!

Conclusions…

…ICT disabled change…

From here…

A&E

Outpatients

Inpatients

Primary Care

ISTC

Mental

Health

AdministrativeRetrospectivePaper driven

…to here?

The patient

Who

Where

Why

When

What

By whom

How

Prior risk

Outcome: expected & actual

Clinical workflow

Booking

Scheduling

Real time

Resource planning

Interactive

Virtual linking of information (not systems)

…via…

• Agility – policies, organisations, patient wants….

• Business disciplines in a political world • Informatics integral to policy development • Business process redesign, ICT-enabled• Supplier capacity & partnership• Financial investment & affordability• HI workforce planning & professionalism

Key lessons from 18 weeks

• Excellent intent

• Spotlights long-recognised weaknesses in the NHS data model and core system

• Major strategic informatics challenge to CFH, the IC, suppliers and the NHS

• Informatics a policy afterthought

• Focus on monitoring not delivery

• We have about 18 months left….