Access 2009 Performance Report 1. Introduction This paper outlines current progress in meeting the Access 2009 Referral to Treatment Time 26 week target. It highlights actions taken to date, key challenges in meeting the 26 week target and further action being taken to ensure the target is achieved by December 2009. 2. Background The Access 2009 Project was developed following publication of the Designed for Life strategy document in 2005. The goal was to reduce waiting times for elective care to a maximum referral to treatment time (RTT) of 26 weeks by 31 December 2009. Waiting times for elective outpatient and treatment waiting lists were in excess of 12 months and the referral to treatment time for many procedures was commonly over two years. The Access 2009 project plan identified key work-streams that needed to be delivered in order to ensure target achievement. These included: Targeted reduction of component waiting times. Developing RTT measurement systems. Reviewing key processes and pathways. Managing demand Improving productivity and efficiency in elective care Progress on these areas is briefly highlighted below. 2.1 Component waiting times Excellent progress has been made by Gwent Health Community and the Health Board in reducing and maintaining component waiting times. Waiting times for outpatient, diagnostic, therapy and treatment times are at their lowest ever levels. This has put the Health Board in a strong position to meet and sustain the RTT target. Page 1 of 11
2.2 RTT Measurement The measurement of RTT has proved to be a significant challenge for all health organisations across Wales. The Health Board s secondary care services have the oldest Patient Administration System (PAS) in Wales. There are significant limitations in the way in which information can be captured and measured. Technical solutions have been developed to improve the quality of information and work is ongoing to improve the accuracy of reporting. A recent assessment by the Delivery and Support Unit suggests that the Health Board s measurement systems are improving and that minor modifications to the reporting are needed to ensure that the RTT reports will accurately reflect RTT performance. 2.3 Reviewing key processes and pathways Work is ongoing to deliver a range of pathway and process improvements which will improve the Health Board s ability to provide the right service at the right time for the right patients. 2.3.1 Pathway Development The referral pathway development workstream, pathway transformation and National Focus On programmes have been developed to ensure that referrals are appropriate and unnecessary steps in the process are identified and removed. Pathways have been developed using joint workshops involving representatives from primary and secondary care. Within Gwent, primary care champions have been appointed to provide clinical input to a range of priority services and are providing the lead in pathway development and act as a communication conduit back to the Local Medical Committee. Patient involvement has been via representation from the patient s panel. A representative sits on the Primary Secondary Care Interface Board which approves all referral guidelines and patient information literature. Patient information is developed as part of the pathway. The work currently in progress relating to elective care is summarised below: Page 2 of 11
Directorate Pathway Current Progress Dermatology Childhood Acne and Eczema Workshop held on 18 September. Follow up workshop & implementation meeting planned for 2 November ENT Tonsils and recurrent sore throat pathways Tonsils U12 pathway in place and currently being evaluated with potential to expand to U16s. Sore throat pathway being developed via Focus on workstream. Otis Externa ear) Media (Glue Work commenced and future state developed. To be taken up by Focus on national pathway workstream. General Surgery Gallstones Pathway agreed. Electronic referral template being rolled out. Hernia Varicose Veins Hernia pathway now in place at RGH. Rolling out to CDMH in November. Currently being reviewed by INNF workstream Gynaecology Menorrhagia Second draft of referral guidelines being developed following follow-up pathway meeting on 25 Aug 2009. Electronic referral template to be developed and released in the New Year. Gastroenterology Iron Deficiency Anaemia Awaiting sign off of second draft of pathway. To be released in the New Year. Musculo-Skeletal Back Pain Pathway signed off at meeting on 8 September 2008. Awaiting localisation on Map of Medicine. MPT3 leaflet being developed. Page 3 of 11
Knee Pain Pathway signed off at meeting on 8 September 2008. Awaiting localisation on Map of Medicine. Template to be rolled out in the New Year. Hip pain Pathway signed off at meeting on 8 September 2008. Awaiting localisation on Map of Medicine Carpal Tunnel Syndrome First draft currently in circulation for comment. Ophthalmology Cataract Pathway developed and waiting formal departmental sign off. New referral forms have been agreed. Patient information leaflet produced. Glaucoma Currently being taken forward as part of Focus on programme. National pathway being developed. 2.3.2 Process Improvement In order to meet the Access target work has been ongoing to ensure core processes are aligned and reviewed to minimise time delays between key steps in the patient pathway. Some of the core work-streams are highlighted below: From this month, GPs will be able to make electronic referrals into the Trust booking centre. The roll out to 77 GP practices is planned. The development of a generic referral template has been supplemented with condition specific templates to enable key clinical information to be captured at the point of referral and enabling the processing of referrals to be streamlined. Work within the Health Board has started to develop an electronic internal messaging system to allow referral to be electronically reviewed and prioritised by clinicians. Outpatient booking processes have been reviewed and patient focussed booking is being rolled out across specialties this year. This has had a significant impact in reducing DNA rates in key specialties and provides a better choice for patients. Page 4 of 11
Improvements have been made to pre-operative assessment (PAC) processes resulting in a significant increase in PAC capacity. This had previously been identified as a bottleneck in the pathway in surgical specialties. From 23 November ward D5East at the Royal Gwent Hospital will become a multi-specialty pre-assessment area and day of surgery admission (DoSA) lounge. This will improve DoSA performance and patient flow. Patient scheduling changed from August 2009 to focus on scheduling by Referral to Treatment Time rather than by component wait. This has enabled the Health Board to start to tackle the RTT backlog which is necessary to meet the RTT target. Over the last three months significant validation of patients on referral to treatment time pathways has been undertaken to allow the Health Board to accurately identify the cohort of patients to be treated over the last two months of the year. This has also enabled follow up waiting lists to be validated, as this has traditionally been an area that has not been frequently reviewed in the past. 2.4. Productivity & Efficiency The delivery of the access target requires significant additional capacity to be provided across a range of specialties. In order to reduce the overall cost of target achievement a range of productivity and efficiency targets have been highlighted as being key to target delivery. Progress against some of these key efficiency and productivity targets are highlighted below. 2.4.1 Use of theatre time Admissions with planned procedure not carried out 5% Elective IP admissions with planned procedure not carried out Gw ent Wales Target 4% 3% 2% MONTH Page 5 of 11
Although the percentage of elective admissions where a planned procedure was not carried out increased slightly in September, performance remains better than target and the Wales average. Operations cancelled at short notice Operations cancelled at short notice 12% 10% Gw ent Wales Target 8% 6% 4% 2% 0% MONTH The percentage of operations cancelled at short notice (on the day or the day before planned surgery) has continued to steadily decrease over recent months. This is despite the dampening effect of the recent switch to 12 month rolling averages to report performance against the efficiency measures. 2.4.2 Day case rates Elective cases treated as a day case 70% 68% 66% 64% 62% 60% 58% 56% Elective cases treated as a day case 54% 52% Gw ent Wales 50% MONTH Page 6 of 11
Although the 75% target for overall day case rates has not yet been achieved by ABHB, progress has been good and performance has been consistently better than the Wales average. Basket procedures Basket Procedures - September 2009 100% Gw ent Wales Target 90% DAYCASE RATE % 80% 70% 60% 50% 40% 30% 20% 10% 0% Breast Tympanoplasty Myringotomy Polypectomy Lap Chole Inguinal Hernia Umbilical Hernia Ops - Uterus Lap and Procedures Ops - Fem Incont Dupuytren s Arthroscopy - Knee Ops - Bunions Ops - Foreskin PROCEDURE Since April 2009, an improving trend has been apparent for all basket procedures. This is despite the dampening effect of the recent switch to 12 month rolling averages to report performance against the efficiency measures. 2.4.3 Contractual Performance The plan to reduce expenditure on meeting Access targets includes maximising the use of former Long Term Agreement (LTA) funded capacity. Currently the Health Board has delivered an additional 1,051 elective treatments and 4,559 outpatients over planned contractual activity, despite an increase in emergency demand of 10.4%. Page 7 of 11
7000 Cumulative LTA performance to end of September 2009 NUMBERS OF CASES ABOVE/BELOWPLAN 6000 5000 4000 3000 2000 1000 0-1000 -2000-3000 new OP DC elective IP emergency IP assessed out emergencies treatments emergency demand TYPE OF ACTIVITY 2.5 Demand Management A demand management workstream led by the Primary & Secondary Care Interface Board is currently looking at several work-streams. Work to date includes: The GP peer review programme designed to facilitate peer review of referral practice, improve communication between consultants and GPs and look at alternative options for dealing with patients outside primary care Referral pathway and e-referral project designed to improve the referral guidelines information available to GPs and facilitate the electronic transmission of referrals to secondary care. Interventions Not Normally Funded (INNF) workstream looking at non-evidenced based interventions. Referral patterns and demand Consultant to consultant referral Currently referrals to secondary care have increased by around 9% in comparison to last year. This workstream is therefore an important workstream to ensure the sustainability of access targets in the future. 3. RTT Performance to Date This section outlines current RTT performance against the Access 2009 target. It should be noted that the Welsh Assembly Government has recently confirmed that the original 100% RTT target has been amended to include some tolerance for clinically complex cases and patient choice. Therefore the minimum targets discussed below include the impact of applying these tolerances. Page 8 of 11
3.1 Closed Pathway Performance The Health Board is expected to achieve a minimum of 98% compliance against the 26 week RTT Closed by Other target. As at the end of September 2009, the Health Board was achieving 93% compliance, having previously achieved 96%. The slight drop in performance reflects targeting the removal of the longer waiting RTT pathways and is an anticipated consequence of reducing the RTT backlog in the short term. The Health Board is also expected to achieve 95% compliance against the 26 week RTT Closed by Admission target. The Health Board was achieving 90% against this target as the end of September 2009. Overall the Health Board has made good progress in improving closed pathway performance over the last eighteen months and this is reflected in the graphs in Figure 1. This shows RTT closed pathway performance against a straight line profile to achieve the target by the end of December 2009. Figure 1: ABHB performance against closed pathway targets % 100 90 80 70 60 50 40 RTT Performance against the 26 week target Closed by Other 100 90 80 70 60 50 40 % RTT Performance against 26 week target Closed by Admission A pr J un A ug O c t De c F eb A pr J un A ug O c t De c A pr Jun A u g O ct D ec F eb A pr Jun A ug Oct D ec Straight line profile Actual Performance RTT performance Straight line profile 3.2 Open Pathway Performance The closed pathway performance is an important indicator of how well the Health Board is doing and ultimately will be used to measure the ongoing performance against the target. However, the true operational performance driver is the number of patients on an open pathway, as this essentially represents the order book that needs to be cleared in order to meet the RTT target. The Health Board has to ensure that a minimum of 95% of all open pathways are within 26 weeks by the end of December 2009. This is the minimum standard indicator used to determine whether the Health Board has met the December 2009 target. Page 9 of 11
Figure 2: Open pathway performance % Open Pathw ays <26 weeks No. of Open Pathways >26 and >36 weeks 100% 95% 90% 85% 80% 16/08/2009 23/08/2009 30/08/2009 06/09/2009 13/09/2009 20/09/2009 27/09/2009 04/10/2009 11/10/2009 18/10/2009 25/10/2009 6000 5000 4000 3000 2000 1000 0 16/08/2009 23/08/2009 30/08/2009 06/09/2009 13/09/2009 20/09/2009 27/09/2009 04/10/2009 11/10/2009 18/10/2009 25/10/2009 >26 >36 Figure 2 shows a sustained improvement in open pathway performance over the last three months. As at the end of October 93.4% of all patients on an open pathway had waited less than 26 weeks for treatment. The latest figures suggest a reduction in line with projection to meet the target for patients waiting longer than 26 weeks but a slight deterioration in reducing the >36 week cohort of patients. The Health Board is required to ensure no patient waits longer than 36 weeks by the end of December 2009. The increase in this cohort is associated with system reporting changes. >36 week reduction against a straight line profile of zero by end November 2009 3000 2500 2000 1500 1000 500 0 16/08/2009 30/08/2009 13/09/2009 27/09/2009 11/10/2009 25/10/2009 08/11/2009 22/11/2009 6000 5000 4000 3000 2000 1000 >26 week reduction against agaist a straight line profile of zero by end of December 2009 0 16/08/2009 30/08/2009 13/09/2009 27/09/2009 11/10/2009 25/10/2009 08/11/2009 22/11/2009 Actual >36 w eeks Profile to zero Actual >26 w eeks Profile to zero 4. Conclusions and Recommendations Overall the Health Board continues to make good progress against the access targets. However there are information systems issues that are currently being actioned to improve the accuracy of RTT reporting. In order to mitigate against any adverse impact of potential data changes, the Health Board is currently putting in to place a tracking system to ensure that each specialty can identify and track individual patients to ensure that patients are pulled through the system over the next two months. Page 10 of 11
Specialty level plans and profiles to manage the delivery of the target are currently being revised. The next two months are critical in ensuring target achievement and sustainability of the target. The Health Board is asked to note the current work in progress to ensure target achievement by the end of December 2009 and to maintain sustainable levels of service in the future. Report prepared and sponsored by: Judith Paget Director of Planning and Operations 5 th November 2009 Page 11 of 11