the biggest thing since Körner

1. Tactical and strategic informatics challenges of 18 weeks – an acute Trust perspective… the biggest thing since Körner or… Brian Derry ASSIST Vice Chair Director of Informatics The Leeds Teaching Hospitals NHS Trust brian.derry@leedsth.nhs.uk

2. Outline • Where are we now? • Where do we need to get to? • Informatics issues • Conclusions

3. Where are we now? …I really wouldn’t start from here…

4. STOP PRESS LDPs 18 weeks for Admitted patients 85% tolerance Non-admitted patients 90% tolerance By March 2008!!!!!!! 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

5. IP OP

6. Waiting times target coverage OP att nurse X 2nd+ atts X GP ref OP att cons Decision To admit Admit & treat Home Any primary care X X X Other ref 1st att Admit & cancel 2nd+ atts X Decision To admit

7. LTHT Outpatient Attendances 2005/6

8. Where do we need to get to? …to boldly go…

9. NHS Plan “By December 2008 no one will have to wait longer than 18 weeks from GP referral to hospital treatment”

10. 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

11. Definitions…

12. Key issues Scope – services, patients? OP & diagnostics IP Clock starts? Clock stops? Measurement & audit?

13. 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”

14. 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..”

15. 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

16. 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?

17. 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

18. 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!

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22. 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

23. Informatics issues …just a few…

24. 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

25. Organisation Staff group Setting Administrative Process Patient Clinical Outcome Data model Shifting the focus from

26. 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

27. 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!

28. Reducing the burden Monthly: By PCT Stocks Flows: OP/IP = 300 returns/month Accountability  Supporting delivery X!

29. Conclusions… …ICT disabled change…

30. From here… Mental Health Primary Care A&E ISTC Outpatients Administrative Retrospective Paper driven Inpatients

31. …to here? 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) The patient

32. …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

33. 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….