18 Week Commissioning Pathways

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18 Week Commissioning Pathways

• Dr Steve Laitner
• DH Clinical Advisor -18 Week Pathways (GP
  Public Health Consultant)

PhwSI Workshop, Leeds2 October 2007
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The 18 Week Challenge
Drive efficiency and quality in current processes
and models of care
Delivery of 18 weeks
Challenge current models of practice to develop
transformational change
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Needs Assessment
Need Ability to benefit from an intervention
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Demand Management

• Demand management is the process of identifying
  where, how, why and by whom demand for health
  care is made and then deciding on the best
  methods of managing this demand such that the
  most cost effective, appropriate and equitable
  health care system can be developed

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Demand Management

• the support of individuals so that they may
  make rational health and medical decisions based
  on a consideration of benefits and risks

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Actions

• Curtail demand for ineffective services
• Cope better with demand for effective services
• different place
• different way
• different people
• different time
• Create demand

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Health Care Pyramid
Dr S Laitner 2007
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Pathway Components for service provision

• Prevention (health education, screening, .)
• Data (incidence, prevalence)
• Supported self care (information, support)
• Triage (escalation thresholds, red flags)
• Clinical Assessment

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Pathway Components for service provision

• Diagnostic tests
• Informed decision making
• Treatments (self care, watchful waiting,
  medication)
• Rehabilitation and review
• LTC management
• QoL outcome measurement

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Development of 18 Week Commissioning Pathways

• Development of condition and symptom based (where
  possible) good practice 18 week commissioning
  pathways for the highest volume 12 specialties
• To
• Challenge existing practice
• Utilise service improvement tools and techniques
• Maximise opportunities for transformational
  change
• Support commissioners to deliver 18 weeks
• Commenced publication January 07

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Principles (1)

• Clinically driven pathways that commence at the
  patients presentation of symptoms and end at
  completion of the patients journey i.e. should
  not start at clock start or end on the point of
  first definitive treatment and clock stops for 18
  weeks.

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Principles (2)

• Pathways must not be defined by whether they are
  delivered in primary or secondary care, or by
  which specialty or professional. Elements of the
  patients pathway must be defined by the
  competency of the individual they are required to
  see and the equipment required NOT whether it is
  primary or secondary care provided.

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Principles (3)

• Be patient focussed e.g. reflect the patients
  view of when the pathway starts and finishes, as
  well as their health needs and preferences.

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Process for Development (1)
Agreed condition and symptom based pathways to
work on following feedback from clinical leads
Reviewed existing research on each
pathway (existing pathways, systematic reviews,
clinical guidelines)
Developed and agreed generic 18 week pathway
template for populating
Identified Project Leads for each
specialty Leading the development of the pathways
working with identified clinical leads, and
projects/workstreams Established working group of
project leads and additional support posts to
prevent overlap etc
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Process for Development (2)
Identified clinical leads and launch of Clinical
Advisory Group Royal Colleges invited to submit
clinical leads through Stakeholder Board Further
clinicians identified through existing groups
CAG membership and terms of reference agreed.
Development of pathways Drafts of populated
pathways using NICE and other guidance
Diagnostics developed through existing routes to
feed into pathways Examples of good practice
included from Imaging, Physiological Measurement,
Pioneers, CITEC sites etc
Gaining Consensus Published initial
versions Amended where appropriate according to
feedback Local events to share and discuss
content Consensus events
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Summary Points from Pathways (1)

• Impressive clinical engagement and enthusiasm
  from individuals and colleges
• Encouraging clinicians to focus on thresholds for
  clinical assessment, diagnostics, referral, and
  interventions, using existing clinical guidelines
• Importance of self care and self assessment
  (supported and unsupported) to manage demand at
  beginning of pathway before 18 week clock
  commences

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Summary Points from Pathways (2)

• Importance of robust primary care assessment -
  red flags, diagnostic tests, diagnosis, treatment
  (and remote specialist advice when necessary)
  before 18 week clock commences
• Highlight the mechanisms to manage demand for
  interventions of limited clinical effectiveness
  such as varicose vein surgery, tonsillectomy
• The importance of patient/ carer information to
  guide informed decision making at all stages and
  for all interventions

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Next Steps

• Development of phase 2 of the pathways following
  consensus
• Workforce skills and competencies
• Technology
• Service improvement
• Quality of life
• Decision aids
• Incidence and prevalence
• Primary Prevention
• HRGs and OPCS
• Green Flags
• Commissioning levers to support implementation

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• There are no short cuts to any place worth going
• Beverly Sills
• slaitner_at_ntlworld.com 07771 625205