Download Delivering a 26 week patient pathway

Delivering a 26 week patient pathway
Proposed Principles and Definitions
A Consultation document by 2009 Access Project Team,
Health and Social Care Department,
Welsh Assembly Government
December 2005
Delivering a 26 week patient pathway
Contents
Introduction
2
Consultation Process
4
Criteria
6
Overview of the Patient Pathway
7
The Targets For Waiting Times
8
Start of the Pathway – Clock starts
9
Diagnostics, Therapies and Mental Health
13
The Patient Pathway
14
End of the Pathway – Clock stops
17
Performance Reporting and Performance Management
20
Conclusion
21
Next steps
22
Appendix A – Diagnostic and Therapy Services
22
Circulation List
23
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Delivering a 26 week patient pathway
INTRODUCTION
1. In March 2005, the First Minister and Minister for Health and Social Services
announced that, by December 2009, no patient in Wales will wait more than 26
weeks from GP referral to treatment, including waiting times for any diagnostic
tests and therapies required. This objective sits within the broader strategic
direction for the health of the people of Wales and is set out most recently in
Designed for Life which describes this vision to 2015.
Designed for Life makes the commitment that:
“…action will be taken year-on-year to reduce waits for treatment so that by
December 2009 we will achieve a wait of no more than 26 weeks from GP or
dental referral to treatment (including diagnostic and therapy treatment).”
2. Following detailed work by the Department of Health and Social Care,
supported by RKW, the Cabinet announced in September 2005 that further
investment will take place to secure improvements in the health of the nation,
including improving access targets. Associated with this was a commitment to
produce a delivery plan for the December 2009 targets for presentation to
Ministers by the end of the year.
3. The delivery of the 26 weeks commitment is being planned through a project
delivery team process known as the 2009 access project. In developing this
consultation document, the 2009 access team has held two events with a number
of NHS Wales stakeholders. One of the workstreams for 2009 access project is
data definitions and measurements. This consultation document forms the first
milestone of this work.
4. Currently the Trusts, LHBs and the Health and Social Care Department, collect
and analyse data on activity (outpatients, day cases and inpatients), numbers of
patients waiting and waiting times. The measurements are of completed
episodes of care, e.g. an outpatient appointment, an inpatient or day case
episode. Although there are definitions of what constitutes a day case, inpatient
and outpatient, it is considered that further work needs to be done to define the
categories in the light of current service developments.
In recent times, data on a subset of diagnostics and therapies has been collected
manually and this data has been valuable for informing the delivery plan. DSCN
18/2005 gives notice of publication in February 2005 of this subset of diagnostics
and therapy waiting times. This will support the proposed SaFF targets for
2006/07 on diagnostics and therapies.
Currently, patients may also be suspended from the active waiting list if they are
not medically fit or unable to have the episode of care because of social reasons.
In addition, the duration of an individual patient episode varies according to a
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Delivering a 26 week patient pathway
number of factors, including the exact measuring points for start and finish of the
episode.
5. The target for December 2009 will have a considerable effect on both
measurement of the target and how the pathway is defined and also current
waiting list management practice. The workstream group established to
undertake this work will address a number of these areas.
6. To support this work, early adopter sites will be identified to take some of this
end-to-end measurement forward.
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Delivering a 26 week patient pathway
CONSULTATION PROCESS
1. Delivering the commitment of a 26 week patient pathway requires a different
approach to delivering patient care. In delivering the milestones necessary to
achieve 26 weeks by December 2009, the focus will need to be on the entire
patient journey and not on waiting lists for each of the independent steps of
outpatient, diagnostics and therapies or inpatient/day case treatments.
2. This means that the consultation needs to address each part of the pathway
and those people and organisations that refer, diagnose, treat and otherwise
interact with patients. We are sharing this document with representatives of
the Health and Social Care Department, NHS Wales Trusts, Local Health
Boards and with a range of organisations representing patients, clinical
stakeholders and other NHS Wales interests. We very much welcome your
views on any or all of the issues covered.
3. This consultation document details the underlying principles and definitions
for 26 weeks as currently proposed by the Health and Social Care
Department. The document follows the patient through the 26 week journey
and covers the following areas:

Start of the pathway – clock start

Referrals for diagnostics, therapies, and mental health services

Along the pathway – clinically complex cases, consultant to consultant
referrals and multi organisation pathways

End of the pathway (start of treatment) – clock stop
4. The 2009 data definitions workstream group will collate the responses and
finalise these principles and definitions and obtain approval from the 2009
Project Board.
The 2009 project team will link to the Designed for Life review on
commissioning so that the decision on the ownership of the target reflects the
proposed structure for commissioning.
5. The consultation period will last for 4 weeks from 15th December 2005 until
27th January 2006. Please send or email comments to:
2009 Project Manager
Delivery & Support Unit
Innovation House
Bridgend Road
Llanharan
CF72 9RP
[email protected]
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Delivering a 26 week patient pathway
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CRITERIA
6. In developing the proposed principles and definitions for NHS Wales, we have
taken into account the following criteria:

Sustainable improvements to the patient experience – ensuring
that the 26 week patient pathway drives sustained improvements and
reduced variation in patient experience and that patients do not
experience ‘hidden waits’

Simplicity, clarity and transparency – ensuring that the 26 week
patient pathway is easy to understand, both for patients and the public
and for the NHS staff responsible for ensuring that patients are able to
start their treatment within 26 weeks

Consistency with the commitment given in Designed for Life – the
standards expressed in the SaFF process and Balanced Scorecard

Reinforcing positive behaviours – ensuring that the principles and
definitions encourage the right behaviours amongst NHS staff, NHS
provider organisations and NHS commissioners

Resilience – the need to have a set of principles that will remain
workable and robust in the changed environment of 2010 and beyond
in a patient-centred NHS

Burden on NHS – avoiding any unnecessary increase in NHS data
collection requirements
7. Although initially some areas might not be specifically included within 26
weeks, we would expect the principle of shorter waits, reduced variation and
sustained improvements for all patients to be implemented across the service.
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Delivering a 26 week patient pathway
OVERVIEW OF THE PATIENT PATHWAY
8. The diagram below outlines the overall 26 week pathway. The rest of this
document discusses each heading in more detail.
Patient chooses to wait longer after reasonable offer of Treatment,
exceptions for clinically complex pathways
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Delivering a 26 week patient pathway
The Targets For Waiting Times
9. The proposed waiting times targets are as follows.
Outpatients Waiting Times
Date target to be achieved
Waiting time target
March 2007*
8 months
March 2008*
6 months
March 2009*
4 months
*Exclusive of diagnostics & therapies
Inpatients and Daycase Waiting Times
Date target to be achieved
Waiting time target
March 2007*
8 months
March 2008*
6 months
March 2009*
4 months
* Exclusive of diagnostics & therapies
In 2006/7 one pathway will be measured from end to end as part of a SaFF
target. The early adopter sites will be undertaking end to end measurement of
pathways in a number of pathways.
Diagnostic and Therapy Services (see Appendix A for list of principal
inclusions and exclusions)
March 2007
March 2008
March 2009
Specific diagnostic tests
36 weeks
16 weeks
8 weeks
Specific therapy services
36 weeks
24 weeks
16 weeks
Some of the annual targets for specific pathways may be reduced further if the
early adopter sites identify key pathways that can meet reduced waiting times
earlier than initially planned.
Patients with more urgent conditions must be treated within specified
timescales
10. The commitment describes 26 weeks as a maximum wait and, of course there
are patients for whom more urgent treatment is necessary. Some of these
treatments already have shorter waiting time targets or standards e.g. cancer,
angiography and cataracts. The 26 week target will not replace these.
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START OF THE PATHWAY – CLOCK STARTS
Referral – the start of a journey
11. For the majority of patients, the start of the elective pathway begins at GP
referral to a consultant in secondary care. We propose to include also
referrals to medical consultants who work in the community. Importantly we
also are considering including direct referral from GP to or for diagnostics and
therapies.
12. The clock will start at the point when the provider receives the referral. We are
also considering the clock starting at the date of the referral letter. We
welcome your views on this.
13. In the event that a patient is booked into a clinic for what proves to be the
wrong specialty, and needs to be re-referred to the correct specialty, the clock
would still be considered as having started from the time the first appointment
was booked. The patient is continuing on the pathway and has experienced
the wait.
14. The 26 week commitment will also cover referrals from:


Dental Practitioners – these referrals are currently treated in the same
way as GP referrals and as such are included in the 26 weeks.
Optometrists – changing pathways for eye care has enhanced the role
of the optometrist. Referrals by optometrists to hospital consultants will
therefore also be counted as the start of the 26 week pathway.
Referral – from other Health Professionals to a Consultant list
15. The principles described in Designed for Life do not identify all health
Professionals and is limited to GPs and Dental Practitioners. However we
would like to consider extending this definition to other professions. We would
welcome views on the challenges or solutions this would offer and what time
scales would be appropriate.
Accident & Emergency (A&E), Medical Assessment Units (MAUs), Surgical
Assessment Units (SAUs) and Clinical Decision Units (CDUs)
16. Any patient who begins their clinical pathway via A&E, CDU, MAU or SAU
and is referred by the consultant to another speciality is covered by the
inpatient (or outpatient) access target. This process should be viewed as a
consultant to consultant referral.
17. In order to ensure that 26 weeks continues to provide a guarantee for these
patients we propose to continue including referrals to hospital consultants
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Delivering a 26 week patient pathway
following attendance at an A&E, Minor Injuries Unit or MAU. These will be
treated in the same way as a GP referral in terms of being the start point for
the 26 week clock.
National Screening Programmes
18. We propose that, where the outcome of a national screening programme
results in needing further diagnostics or treatment in secondary care, the
clock should start from the point of the receipt of the referral or result of the
diagnostic being known. For example, where the outcome of cervical
screening is that the smear is abnormal and a colposcopy is needed 26
weeks would be applicable (unless the cancer waiting times targets are
applicable). The point at which the receipt of the referral for the colposcopy is
received would start the clock.
Consultant to consultant referrals
19. Where a consultant makes a referral to another consultant for treatment of a
condition other than the one previously identified by the original GP referral,
we propose that this should not be covered in the 26 week target. An example
of this would be a patient who sees an orthopaedic surgeon and who is
referred by the orthopaedic surgeon to a dermatologist for a different
condition unrelated to the orthopaedic pathway. (Consultant to consultant
referrals for the same condition are discussed later in this document).
20. It is generally better practice for these cross condition patients to be referred
back to their GP, so that the GP can decide (in consultation with the patient)
whether a new hospital referral is appropriate. It should be stressed that we
do not anticipate patients having to physically visit their GP in all cases but
primary and secondary care clinicians should communicate using existing
methods for the referral to be discussed. The GP’s acceptance of this second
referral and the receipt of the referral would start another 26 week pathway.
Intermediate services
21. Referrals to intermediate services include referrals to professionals in primary
care such as GPs with a Special Interest (GPwSIs) and Medical Assessment
Units (MAUs) and other organisations intermediary between primary and
secondary care.
22. There are some cases where good clinical practice may support patients
being referred to community based units (e.g. for mental health services) and
for specific presenting conditions such as musculoskeletal conditions.
However, referrals to intermediate services should happen only where this
adds demonstrable clinical value for patients.
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Delivering a 26 week patient pathway
23. In these circumstances, the 26 week pathway could start at one of two start
points, either:
A. At the receipt of referral from an intermediate service to secondary care
or;
B. Receipt of referral into the intermediate service.
We would welcome your views on these two options providing your view of
the benefits patients would derive.
24. Starting the 26 week pathway at the point of receipt of referral in secondary
care (Option A) would reflect developments in the organisation and provision
of services and align with the point at which the patient enters secondary
care.
25. This of course must be balanced with the other demands on the pathway, and
it is important that the focus on the 26 week commitment in secondary care
does not push waits up in primary care. We would welcome views on whether
we need to reinforce primary care policy by starting the 26 week clock from
the receipt of referral in intermediate services (Option B). To avoid having to
start very significant numbers of patient clocks only to stop them at the point
of leaving the intermediate service (if there is no onward referral to secondary
care), we would propose (if Option B were adopted) to set the clock only
when the patient is referred on to secondary care but with the clock starting
retrospectively at the date of receipt of GP consultation.
26. We are aiming to reduce the entire experienced wait to 26 weeks and we
would be interested in your views on whether this retrospective count is
possible from a practical perspective as well as whether it is clinically
appropriate (clinical exceptions are discussed later in this document) and how
this might impact on delivering the overall 26 week patient pathway.
27. As part of this consultation process, when a range of views has been sought,
we will be holding a workshop involving key stakeholders from across the
service to discuss these options further.
Direct access diagnostics
28. The issues set out above for intermediate services apply similarly to direct
access diagnostics, whether they are provided in primary or secondary care.
We would welcome your views on the following options:
A. Start the clock at the point of receipt of referral into secondary care after
the patient has received diagnostic tests. We would not want waits for
direct access diagnostics to develop and, if it became apparent over time
that waits for these services were creating unmeasured queues for
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secondary care, there would need to be action at local, regional or
national level to remedy this
B. Where a patient is referred on to secondary care following a diagnostic
test, retrospectively set the clock so that it starts at the point of receipt of
the original GP referral for diagnostics
29. We would also welcome input on the appropriate performance standards for
the turn around time for direct access diagnostics where the test does not, or
was never expected to, lead to a referral to secondary care.
Follow-up outpatient appointment
30. There will be a group of patients on long term treatment pathways, typically
patients with long term conditions, whose care is being led and undertaken in
secondary care. The initial GP referral or A&E attendance that began the
pathway may have been many weeks, months or even years before and may
have involved multiple outpatient attendances and diagnostic procedures.
31. Where a decision to treat is made at a follow-up outpatient appointment for
these patient groups, we would generally expect the GP to have the
opportunity to agree that further hospital treatment is the best way of
proceeding. To avoid patients necessarily having to physically return to their
GP, this could be done via communication between primary and secondary
care.
32. We propose that in these circumstances, a new 26 week clock should
normally only be started through confirmation by primary care that treatment
is appropriate. Clearly, this should not prevent a decision to treat in cases of
clinical urgency, although the consultant would need to communicate this
decision to the GP to ensure all those involved are appropriately informed.
33. We welcome your views on the issues raised in each of the above sections.
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DIAGNOSTICS, THERAPIES AND MENTAL HEALTH
34. Initially raised in Improving Health in Wales- A Plan for the NHS with its
Partners, the Waiting Times Strategy, launched in July 2001, gave a
commitment to extend publication of waiting times to include diagnostic and
therapy services. The first tranche of waiting times for diagnostic and therapy
services is due to be published in February 2006 (WHC (2005) 078) and
includes imaging, physiological measurement and therapies. Initial work is
showing that some long waits currently exist and that the pattern is variable
across health communities in Wales.
35. Designed for Life develops the commitment to publish by including diagnostic
and therapy services in the total 26 week pathway. Whilst many diagnostics,
and some therapies and health care science interventions will fall within the
acute services pathway, a significant proportion are delivered in community
settings or hospital based direct access clinics. We do not want waits for
these direct access treatments to develop.
36. In order to reduce the risk of waits developing for those diagnostic and
therapy services currently reporting waits, a 36 week maximum wait for
diagnostic and therapy services will be included in the SaFF target for 2006/7.
37. A table of diagnostic and therapy services currently being considered for
inclusion and exclusion is at Appendix A. All endoscopies currently classified
as diagnostic or therapeutic will be combined and classified as a single
definition of “Endoscopy” for measurement of the 26 week pathway.
38. Two options for diagnostic and therapy services in which the 26 week
pathway will apply are currently being considered:
A. The appropriate performance standard for the turn around time for direct
access diagnostics, therapy and healthcare science interventions, where
the test does not, or was never expected to, lead to a referral to secondary
care.
B. Where a patient is referred on to secondary care following a diagnostic
test, therapy, or healthcare science intervention retrospectively set the
clock so that it starts at the receipt of the GP referral.
39. We would welcome your views on the above issues and your preferred choice
from the above options, providing any practical issues you foresee with
solutions where you are able to provide them.
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Delivering a 26 week patient pathway
THE PATIENT PATHWAY
Patient exclusions
40. There are two groups of patients for whom it would be inappropriate to expect
treatment to begin within 26 weeks:
A. Patients with genuinely complex diagnoses or for whom the appropriate
treatment is unclear
B. Patients who wish to choose appointments for a later date than that
previously offered.
41. To allow for these two groups, we propose to set an operational standard that
the number of patients waiting more than 26 weeks, either for clinical reasons
or for reasons of personal choice, should not exceed a fixed percentage of
total referrals (i.e. a tolerance level).
Clinically complex cases
42. There will be occasions when it is not clinically appropriate for treatment to
begin within 26 weeks of referral, for instance where a series of tests needs to
be done in sequence, or where the patient and consultant have agreed that
the patient should receive a second opinion. We propose that clinically
complex cases such as these should be covered by an operational standard,
rather than allowing a suspension facility. This approach follows the principle
applied successfully for the A&E operational standard.
43. LHBs and Trusts would need to be able to demonstrate that cases within this
margin of tolerance were genuine clinical exceptions, but currently we are not
being prescriptive about the precise form of audit trail needed for this
purpose. To ensure transparency, LHBs and Trusts would have to report the
length of all waits (i.e. including the longer waits covered by the tolerance).
This would enable Regional Offices to identify quickly if patients waiting more
than 26 weeks were left waiting for an unacceptably long further period. We
would welcome your views on this.
Patients who choose to wait longer
44. By 2009, NHS Wales will offer all patients treatment within 26 weeks where it
is clinically appropriate. Some patients may decide to wait longer for reasons
of personal choice. Where it is clear that later treatment is at the request of
the patient, the delay will not be counted as a breach of the waiting times
target. LHBs and Trusts will have to be able to demonstrate that the patient
has understood that they would have to wait longer for treatment, and that the
patient accepted responsibility for their decision.
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45. In those circumstances where demand for a particular provider or clinician
starts to exceed capacity, this should be identified as soon as possible and it
would be the joint responsibility of the provider and the LHB(s) to agree a
management plan. Generally, it will be the provider’s responsibility to ensure
that they expand or reduce capacity to reflect demand.
46. Even where the provider has offered earlier appointments, patients may
choose a later first outpatient appointment, or a later appointment for
subsequent outpatient appointments, subsequent diagnostics or the start of
their treatment. These later appointments may be more convenient for the
patient for personal or social reasons, but could mean that the provider
cannot then guarantee a maximum 26 week wait.
47. We propose that the operational standard should allow a margin of tolerance
for patients waiting more than 26 weeks for reasons of personal choice. As
with clinical exceptions, LHBs and Trusts would have to be able to
demonstrate (if asked or challenged) that cases within this margin of
tolerance were genuine instances of patient choice. This would enable
individual patients to be assured that they should not have to wait more than
26 weeks unless they choose a later date than those being offered or that
they fall within the small group of patients where there are clinical reasons for
deferring start of treatment.
48. There will be an operational standard for patients who choose to wait longer
and for those clinically complex cases. Patient cancellations should also fall
within this tolerance level. However, in cases where the provider cancels an
appointment, the time would continue to be measured and 26 weeks remains
binding.
49. We believe the combined tolerance for clinical exclusions and patient
choosing to wait longer should be no more than 5%. We would welcome your
views on the appropriate level of tolerance, including any evidence you have
to support your view. We will then set the figure when we publish the final
rules and definitions. We are also keen to hear your views about the principle
of having a tolerance rather than a clinically defined suspension system and
about the practicalities of either option.
Consultant to consultant referrals for the same condition
50. Consultant to consultant referrals for patients with the same underlying
condition are likely to be follow-on referrals after the first outpatient
appointment and should be included within 26 weeks (with the clock starting
at the point of the original GP referral). For example, there may be a referral
from a physician to a surgeon or vice versa, a GI physician to a GI surgeon
for a colorectal condition. In cases of clinical complexity and uncertainty,
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different rules will apply and these are presented in the section on clinically
complex cases.
Tertiary referrals
51. Tertiary referrals are referrals from a consultant in one provider to a
consultant in a tertiary centre (this could be within the same provider
organisation). Where the referral is a standard element of the elective
pathway, these are included within 26 weeks (clock starting at receipt of GP
referral). For example, this would apply to many CHD patients and will include
a range of procedures including angioplasty, cardiac valve repair, heart
bypass surgery and electrophysiology procedures. Other tertiary referrals will
occur in cases of clinical complexity and uncertainty and in such cases the
tolerance principle would apply (unless shorter interim targets apply to
specific procedures). Please see the section on clinically complex cases for
our proposals for this.
Multi organisation pathways
52. For pathways that include multiple organisations, we propose that in cases
where a patient is referred from one provider to another and where the patient
cannot be treated at that provider and consequently needs treatment at the
referring provider, the patient should still start treatment within 26 weeks.
53. With regard to specialised services, there might be occasions where initial
diagnostic processes eliminate the more common diagnoses but then more
complex diagnostic tests (possibly in another unit) are needed before
treatment can begin. In cases of clinical complexity and uncertainty, the rules
for clinically complex cases will apply. However, where patient pathways
involve multiple organisations but are not clinically complex, 26 weeks still
applies.
54. Further work will be done on developing the performance assessment system
supporting 26 weeks. Performance assessment arrangements for multi
organisation pathways will play a key part in this process.
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END OF THE PATHWAY – CLOCK STOPS
55. The end of the pathway, when the clock stops for 26 weeks, will be at the
start of definitive treatment. Start of definitive treatment will be defined as the
start of the first treatment that is intended to ameliorate, stabilise or cure a
person’s disease or injury. For the purpose of 26 weeks, the start of
treatment, includes the following actions and decisions:
Treatment as inpatient or day case
56. The patient is admitted as a day case or inpatient for treatment. The date of
the clock stopping will be the date of admission, as is currently the case. If
patients are then cancelled, the clock will restart from the point of the earlier
stop.
Treatment in outpatients
57. Treatment undertaken in an outpatient setting (surgical, medical or treatment
provided by an Allied Health Professional (AHP) or mental health and learning
disability professional), where no further inpatient episode is expected, can
stop the clock. Diagnostic episodes prior to admission for treatment do not
represent the end of the pathway for purposes of 26 weeks and in these
cases are part of the diagnostic process rather than the start of treatment.
58. Where treatment starts in parallel with diagnostic testing and in advance of a
definitive surgical procedure, the start of this particular treatment does not
count as the end of the pathway and therefore the clock does not stop.
Examples would include treating skin lesions with topical cytotoxic in advance
of a surgical procedure; an orthopaedic surgeon prescribing pain control or
anti-inflammatory drugs to manage the condition whilst the patient waits for
the actual operation; a psychiatrist prescribing drug treatment whilst the
patient waits for the start of Cognitive Behaviour Therapy. The key issue is
that the clock will continue ticking whilst the clinician is managing the
condition ahead of the start of definitive treatment.
59. The date the clock stops will be the date of attendance in outpatients for those
patients whose treatment starts in outpatients.
Fitting of a medical device
60. Where a consultant decides that treatment should include fitting a medical
device (e.g. a hearing aid), we propose that the clock stops at the point of the
patient being measured for the device. More complex fittings (e.g. prosthetic
limbs) are much less likely to come at the start of a treatment pathway. If this
is at the start of treatment, they are likely to be among the cases covered by
the proposed tolerance for clinically complex cases.
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Therapeutic treatment
61. Some procedures will include both a diagnostic test and a therapeutic
treatment. There are also some procedures that are intended as diagnostic
but the healthcare professional makes a decision to undertake a therapeutic
treatment at the same time. Both these examples could count as an initiation
of definitive treatment and as such the clock would stop. Many endoscopies
could fall into this category (e.g. a colonoscopy), having been started as an
investigative or a diagnostic procedure, could result in being a therapeutic
treatment if, during the investigation, the cause of the problem (such as a
polyp) can be removed.
First-line treatment
62. In some pathways less intensive treatments and medical management may
be attempted before moving on to more invasive procedures and treatment. In
such cases, the initiation of the first treatment would count as the initiation of
treatment and therefore the end of that particular 26 week pathway. Should
the patient at some later stage require more aggressive treatment then this
subsequent treatment would not fall within 26 weeks, unless primary care
confirms the treatment through another referral (also see the section on
follow-up outpatient appointment).
Follow-up inpatient treatment
63. Some patients require follow-up inpatient treatment, sometime after the
original admission (i.e. removal of metalwork following an orthopaedic
procedure, second cataracts). Patients waiting for an admission of this kind
will be placed on a planned list.
64. For follow-up operations, such as second cataracts or removal of metalwork
following orthopaedic procedure, it is proposed that these would be planned
cases, which will however be subject to the 26 week maximum wait. In this
scenario, the clock would start from the point of the decision to treat being
made for the follow-up operation, either at an outpatient appointment or
directly following the first inpatient treatment or at a date specified postoperatively.
Other points at which the clock stops
65. The patient is returned to primary care either after outpatient attendance or
after diagnostic testing. When a decision not to treat on secondary care is
made and the patient informed, the clock will stop.
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66. A decision to treat is made but the patient declines treatment. The date the
patient declines treatment should be used as the clock stop date.
67. There will be patients for whom a period of active monitoring is appropriate.
On this occasion, the clock would stop at the point where the decision is
made (and communicated to the patient) that treatment will not start but that a
period of active monitoring is appropriate. In essence, this will be the start of
non-treatment. If a patient subsequently requires further treatment, this would
follow on from the period of active monitoring and the decision to treat would
start a new 26 week clock. The patient would not necessarily need to return to
primary care although the consultant would be expected to keep the GP
updated with the progress of their patient (see also the section on follow-up
outpatient appointment).
68. Where patients repeatedly fail to respond to attempts to agree a date for an
appointment (at any stage of the pathway), the patient can be returned to
primary care and the clock would stop. The provider can write to the GP to
indicate that the patient would need to be referred again if treatment was still
needed. We propose that two attempts are made to agree a date and then if it
has not been possible to agree a date, the patient is referred back to the GP.
69. Patients who have not kept their appointment for admission and have failed to
tell the hospital in advance that they will not be coming, are identified as ‘Did
Not Attend (DNA)’. If the patient does not attend, the clock stops and the
patient should be returned to their GP. If the GP re-refers the patient a new 26
week clock would start.
70. We would like to receive views of the process and equity of the proposed
process.
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PERFORMANCE
MANAGEMENT
REPORTING
AND
PERFORMANCE
71. We will be having further consultation on how performance is measured and
reported. At present, we use a snapshot approach for reporting inpatient and
outpatient waiting times. For inpatients, for example, the Trusts report the
stock of patients waiting for admission on the final day of each month and the
proportion of these patients who have been waiting at that point in time. We
also collect annual data on the actual waits for each patient who has
completed treatment, but it is the snapshot approach that is currently used for
national performance reporting and management. We propose to move to
reporting based on real-time elapsed waits on the patient journey and actual
waits to treatment. We will need to do further work on when and how this can
become operational. This is also a key issue to address, linked to improving
the patient’s experience, and we would welcome your comments on this.
72. It is proposed that this work will be taken forward by the workstream on
performance management.
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Delivering a 26 week patient pathway
CONCLUSION
73. Designed for Life has established that the strategic direction and 2009 access
project is aimed at fulfilling the commitment to reduce waiting times for
patients. Long waiting times will be consigned to history.
74. This objective underpins the development of these draft principles and
definitions that should be maintained when interpreting issues relating to
delivering 26 weeks maximum wait.
75. In the case of uncertainty, NHS Wales should continue to follow the spirit of
the rules and maintain it’s principle of reasonableness to patients and honesty
to the public.
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NEXT STEPS
76. The consultation period will last for four weeks from 15th December 2005
until 27th January 2006.
77. The workstream group on data definitions will consider responses that will be
collated by the 2009 Project team. These principles and definitions will then
be discussed further with colleagues in NHS Wales. The aim is to produce a
final document by April 2006.
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Appendix A – Diagnostic and Therapy Services
Diagnostic and Therapy Services Proposed Inclusions and Exclusions
Proposed for inclusions in the
2009 target - Diagnostic Services
Imaging
MRI
CT
DXA Scans
Non-obstetric ultrasound
Nuclear medicine
Barium enema
Mammography
Endoscopy *
Bronchoscopy
GI Manometry
Other endoscopy
Physiological measurement
Audiology
Neurophysiology
Lung function tests
Echocardiogram
Exercise stress tests
Note: * Endoscopy is shown here
under diagnostics but it may be
undertaken by other specialties. The
proposal is that all endoscopies are
included
Proposed for inclusions in the
2009 target - Therapy Services
Dietetics
Occupational Therapy
Physiotherapy
Podiatry
Speech & Language Therapy
Optometry
Orthotics**
Psychology**
Psychotherapies**
Note: ** The length of wait for these
services is not currently counted
Diagnostic means a test or procedure used to identify a person’s disease or
condition and which allows a medical diagnosis to be made.
Therapeutic is defined as a procedure, which involves actual treatment of a
person’s disease, condition or injury.
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CIRCULATION LIST
78. This paper is being shared with the following organisations. We would
welcome your suggestions as to anyone else we could share this with.
Chief Executives
NHS Wales Trusts
Chief Executives
Local Health Boards
HR Directors
Business Services Centre
Director
NHS Confederation in Wales
Chief Officer
Association of Welsh Community Health Councils
Director
Welsh Local Government Association
Dean
University of Wales, Bangor
Chief Executive
Commission for Racial Equality
Chief Executive
NLIAH
Secretary
British Dental Association in Wales
Postgraduate Dean
University of Wales College of Medicine
Director information services
University of Wales College of Medicine
Secretary
British Medical Association (Wales)
Director
Royal College of Nursing (Wales)
Welsh Council Representative
British Dietetic Association
Wales Secretary
British Orthoptic Society
Chair
Community Pharmacy Wales
Chair
Royal College of General Practitioners
Assistant Director
Chartered Society of Physiotherapists
Officer for Wales
Society of Radiographers
IR Officer
Society of Chiropodists and Podiatrists
Board Secretary for Wales
Royal College of Midwives
Welsh Executive
Royal Pharmaceutical Society of Great Britain
Information Officer
Wales Council for Voluntary Action
National Member for Wales
AMICUS - Guild of Health Care Pharmacists
Business Manager
Institute of Health Care Management Welsh Division
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Delivering a 26 week patient pathway
Chief Executive
Association of Optometrists
Librarian
British College of Optometrists
Director General
Wales Audit Office
Director
Business Service Centre
Patch Managers
Business Service Centres across Wales (6 copies each)
Secretariat
Statutory Committees
Regional Directors
NHS Wales Regional Offices
Chief Executive
Health Commission Wales (Specialist Services)
Chief Executive
Health Professions Wales
Librarian
National Public Health Service
Chief Executive
Welsh Language Board / Bwrdd yr Iaith Gymraeg
Librarian
Health Promotion Library
Chief Executive
Healthcare Inspectorate Wales
Chairman
Medical Director of NHS Trusts
Chair
Medical Directors of LHB’s
Chief Medical Officer
Welsh Assembly Government
Chief Scientific Adviser
Welsh Assembly Government
President
Academy in Wales
Acting Regional Director
Mid and West Wales Regional Office
Regional Director
North Glamorgan NHS Trust
Regional Director
South and East Wales Regional Office
Therapy Adviser
Welsh Assembly Government
Chief Nursing Officer
Welsh Assembly Government
Further circulation: HOWIS website
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