START THE CLOCK STOP THE CLOCK

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START THE CLOCK STOP THE CLOCK
GP and Consultant WorkshopRedwood Education
Centre, GRH 23rd January 2008
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Thank you to our sponsors.
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A G E N D A
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THE SEPTEMBER EVENT

• Explored the Trusts approach to doctor appraisal
  and validation
• Learned about what assurance of competence
  patients expect from doctors
• Explored opportunities for joint working
• Learned about the approach to support GPs

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18 Weeks Why Bother?

• GP / Consultant Meeting
• Sean Elyan
• 22nd January 2008

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Clinical Case(Complaints)

• GP referral wrist problem (? Date)
• March 06 clinic apt tests onward referral
  x-ray
• August 06 seen MRI needed
• Oct 06 - MRI done
• Feb 07 Awaiting OP review

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Clinical Case

• Do we think this is good for patients?
• Do we think we should do better?
• Do we think we could do better?

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Cancer 2 week waitsA view from the other side

• Some process / some capacity
• General feeling - better for everyone
• Secretaries / admin
• Doctors / nurses
• Patients / families
• The pain is worth the gain

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18 weeks - is it worth it?

• When you get over initial hump
• DEFINITELY YES

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Nicola Turner

• 18 Week Project Manager

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18 WEEKS

• Aims of today are to
• 1. Gain a shared understanding
• of the 18 week target principles and rules
• Benefits to patients
• How are we are doing
• Information and data required
• Changes required
• New messages for patients
• Discuss how GPs contribute to identifying and
  making the changes necessary.

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18 WEEKS

• Principles and rules
• What is the 18 Week target
• - stages and milestones
• - what is included and excluded
• The referral to treatment categories
• - clock starts and stops
• What needs to be measured

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18 WEEKS

• 1. Principles and rules
• March 2008 - 85 inpatient treatment
• - 90 outpatient treatment
• December 2008
• Inpatients 90 with 10 tolerance
• Outpatients 95 with 5 tolerance

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18 WEEKS

• 1. Principles and rules
• Three stages
• To first outpatient appointment - 5 weeks
• To decision to treat - 6 weeks
• To treatment - 11 weeks

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18 WEEKS

• Principles and rules
• Referral to Treatment Categories (RTT)
• Clock start
• Clock running
• Clock paused
• Clock stop

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18 WEEKS

• 1. Principles and rules
• CLOCK STARTS
• Any referral from primary care starts the 18-week
  clock if it is expected that
• the patient will be assessed and, if appropriate,
  treated before responsibility is transferred back
  to the referring health professional and
• any treatment will or might be carried out by a
  medical or surgical consultant-led service
  irrespective of setting

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18 WEEKS

• 1. Principles and rules
• CLOCK STARTS
• Upon completion of an 18-week referral to
  treatment period, a new 18-week clock only
  starts
• a) when a patient becomes fit and ready for the
  second of a consultant-led bilateral procedure
• b) upon the decision to start a substantively new
  or different treatment that does not already form
  part of that patients agreed care plan
• c) upon a patient being re-referred in to a
  consultant-led interface or referral management
  or assessment service as a new referral
• d) when a decision to treat is made following a
  period of active monitoring.
• e) when a patient rebooks their appointment
  following a first appointment DNA that stopped
  and nullified their earlier clock

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18 WEEKS

• 1. Principles and rules
• CLOCK PAUSED
• A clock may be paused only where a decision to
  admit has been made, and the patient has declined
  at least 2 reasonable appointment offers for
  admission. The clock is paused for the duration
  of the time between the earliest reasonable offer
  and the date from which the patient makes
  themselves available again for admission.

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18 WEEKS

• 1. Principles and rules
• CLOCK STOPS
• When a clinical decision is made that treatment
  is not required or when first definitive
  treatment begins.
• - Decision not to treat
• - Decision to embark on a period of watchful
  waiting or active monitoring
• - Decision to add a patient to a transplant list
• - Decision to return the patient to primary care
  for treatment - non consultant-led
• - The clock also stops when the patient declines
  treatment having been offered it.

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18 WEEKS

• 1. Principles and rules
• Definitive Treatment
• First definitive treatment is defined as an
  intervention intended to manage a patients
  disease, condition or injury and avoid further
  intervention. (Treatment will often continue
  beyond the first definitive treatment and after
  the clock has stopped.)

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18 WEEKS

• Principles and rules
• Definitive Treatment cont.
• - Inpatient or day-case treatment the clock
  stops on the date of admission
• - Diagnostic tests turn into a therapeutic
  procedures during the investigation for example,
  a colonoscopy which reveals a polyp that can be
  removed there and then

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18 WEEKS

• Principles and rules
• Definitive Treatment cont.
• - The fitting of a medical device, with the
  clock stopping on the date on which definitive
  fitting or trial fitting begins, and with no
  undue delay in subsequent fitting sessions
  thereafter.
• - Outpatient treatment (or medical or surgical
  consultant-led treatment irrespective of setting)
  if no subsequent inpatient or day-case admission
  is expected, with the clock stopping on the date
  of attendance

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18 WEEKS

• 1. Principles and rules
• CLOCK PAUSE
• The act of pausing a patients 18-week clock.
  Clocks may only be paused for non-clinical
  reasons and only where a patient chooses to wait
  longer for admission than two reasonable offers
  made by the provider

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18 WEEKS

• 1. Principles and rules
• Definition of reasonable offer
• Where a decision to admit, as either a day case
  or inpatient has been made, many patients will
  choose to be admitted at the earliest
  opportunity. However, not all will, and it would
  not be appropriate to pause a clock for patients
  who cannot commit to come in at short notice.
• A clock may only be paused therefore when a
  patient has turned down two or more reasonable
  offers of admission dates.
• A reasonable offer is an offer of a time and date
  three or more weeks from the time that the offer
  was made.
• If patients decline these offers and decide to
  wait longer for their treatment, then their clock
  may be paused from the date of the first
  reasonable offer and should restart from the date
  that patients say they are available to come in.
  

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18 WEEKS

• Discussion

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18 WEEKS

• Benefits to patients
• Shorter waits for outpatient appointments
• Expectation that whole pathway should be
  completed within 18 weeks
• Better informed, no undefined waits for something
  to happen

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18 WEEKS

• 3. How are we doing December 07
• Position for admitted patients
• Specialty patients in 18weeks
• General Surgery 409 79
• Urology 112 80
• TO 579 47
• ENT 167 79
• Ophthalmology 450 74
• Oral Surgery 147 86
• Cardiology 54 94
• Gastroenterology 32 94
• Gynaecology 211 82
• Total 2427 74

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18 WEEKS

• 3. How are we doing October 07 (Dec figures
  awaited)

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18 WEEKS

• 3. How are we doing October 07 (Dec figures
  awaited)

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18 WEEKS

• 4. Information and data collection

• Outcome form
• Admissions
• Expanded RTT data
• Monthly reports

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18 WEEKS
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18 WEEKS
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18 WEEKS

• 4. Information and Data collection
• Expanded RTT field within PAS
• Record outcomes not associated with a clinic
  attendance or an admission

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18 WEEKS
4. Information and Data collection
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18 WEEKS

• 4. Information and Data collection
• Patients with paused 18 week clocks are placed on
  a suspended waiting list to ensure we count the
  patients 18 week RTT wait in an appropriate
  manner. Patients who make themselves unavailable
  at this stage for more than 91 days will be
  returned to their GP.
• To ensure compliance with latest guidance active
  waiting lists will be set up for an increased
  range of patients who are currently recorded as
  awaiting a planned procedure - most noticeably
  for endoscopy and pain management.

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18 WEEKS

• Discussion

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18 WEEKS

• 5. Changes
• Demand forecasting and Capacity planning in the
  three stages, outpatient clinics, diagnostic
  services and elective inpatient admissions.
• Reduction in waiting times for the three stages,
  Trust aiming for stage 1, outpatients 4 weeks,
  stage 2 diagnostic 4 weeks, stage 3 inpatients 10
  weeks
• Improved data collection outpatient outcome
  form, expanded RTT

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18 WEEKS

• Changes
• Increased usage of Choose and Book
• Identifying administrative processes for
  improvement
• Identifying waits/delays removing or minimising
• Clinical pathway reviews

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18 WEEKS

• 5. Changes to Diagnostics
• Diagnostic appointment dates being issued within
  48 hrs of an outpatient visit,
• Patients informed that appointments and tests
  will be completed within a set period
• Transferring information electronically between
  hospital sites

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18 WEEKS

• 5. Changes to Follow-ups
• Follow-up outpatients appointments made at
  previous appointment new patients
• Follow up appointments
• Should they exist?
• Should they be primary or secondary care
  based?
• How should the new to follow up ratio be
  defined?

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18 WEEKS

• 6. New message to patients
• Patients start the process with the intention of
  completing within 18 weeks
• Patients consider the appropriateness of long
  periods of unavailability
• Reduction in the DNA rate
• Minimise patient-initiated delays

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18 WEEKS

• 6. New message to patients
• Tension between patient choice and 18 weeks
• Choice of venue within stage milestone
• Choice of consultant generic referrals
• - waiting lists
• Thinking time within the 18 weeks

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18 WEEKS

• 7 Fit to Refer The Role of Healthchecks?
• Basic assessments GPs should perform prior to
  referral for surgical procedure
• Blood pressure,
• Urine test to exclude diabetes,
• Body Mass Index, should be below 40,
• Leg ulcers/other open wounds are exclusion
  criteria with regard to orthopaedic procedures.

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18 WEEKS

• 7 Fit to Refer Unfit Patients
• Where a patient is found to be medically unfit
  at pre-operative assessment and they do not come
  under one of the following criteria
• That they are likely to be medically fit within a
  few weeks
• That the clinical urgency of the operation needs
  to take precedent over the medical condition
• the patient will be removed from the waiting
  list and referred back to their GP until
  medically fit.

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18 WEEKS

• Discussion
• www.18weeks.nhs.uk