Clinical responses to the downturn

Clinical responses to the downturnSeven medical specialties address how they can help tackle the NHS financial challenge

JMCCJOINT MEDICAL CONSULTATIVE COUNCIL

Produced in partnership with

the voice of NHS leadership

The Joint Medical Consultative CouncilThe JMCC brings together the organisations that represent the medical profession in the UK. We provide a constructive forum in which our members can meet, debate and unite on the issues that affect the practice of medicine and the delivery of healthcare in the UK. We therefore aim to:

act as a voice for a united medical profession•

influence policy and inform the wider public debate•

engage with key stakeholders and build partnerships •to add real value.

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The Academy of Medical Royal CollegesThe Academy of Medical Royal Colleges promotes, supports and facilitates the work of the Medical Royal Colleges and their Faculties. It has a leading role in the areas of doctors’ revalidation, training and education and aims to speak with a clear and sure voice on generic healthcare issues for the benefit of patients and healthcare professionals.

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The NHS ConfederationThe NHS Confederation is the only independent membership body for the full range of organisations that make up today’s NHS. We represent over 95 per cent of NHS organisations as well as a growing number of independent healthcare providers. Our ambition is a health system that delivers first-class services and improved health for all. We work with our members to ensure that we are an independent driving force for positive change by:

influencing policy, implementation and the •public debate

supporting leaders through networking, sharing •information and learning

promoting excellence in employment.•

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The British Medical AssociationThe BMA is an independent trade union and voluntary professional association, which represents doctors and medical students from all branches of medicine all over the UK. We have a membership of over 143,000 worldwide. We promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.

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Contents

Foreword 2Howtoreadthisreport 3 Neurosurgery 4Geriatrics 9Vascularservices 13Pathology 17Orthopaedics 28Neonatology 32Dermatology 36

Clinical responses to the downturn 04

Dr Mark Porter, Chair, Consultants Committee, British Medical Association

Professor Sir Neil Douglas, Chairman, Academy of Medical Royal Colleges

Professor Hugo Mascie-Taylor, Medical Director, NHS Confederation

Dr Alan Russell, Chairman, Joint Medical Consultative Council

ForewordTheoneconstraintwesetwasafirmfocusonthepracticeandbehaviouroftheirownspecialty’smembers–theareainwhichtheyhavethemostauthority.Onlyattheveryendofeachmeetingdidweallowashortperiodtodiscusswhattheyfeltotherpeoplecoulddotoaddressthechallenge.

Weweredelightedandsurprisedattheeasewithwhichwewereabletoengagewithorganisations.Notoncedidanygrouprefusetoparticipate.Theenthusiasmthatweencounteredwasdrivenbyadesirebytheparticipantstoshowleadershipinacrisisandawillingnesstotakeariskinrecommendingthingsthatevensomepeoplewithintheirspecialtywouldnotnecessarilyagree.Wecommendtheirlong-sightednessinseeingthatclinicianscanonlyprovidethebestpossiblecareiftheresourcesavailabletotheNHSareusedwell,andthatwasteanywhereinthesysteminevitablymeansamorelimitedorworsequalityservice.

Weseeourmethodandthisreportasafirststage.Therearemanymorespecialtieswecouldhaveengagedwithinthisproject,andindeedwhichhavealreadyapproachedus,butwewantedtopublicisethefindingsfromtheinitialphasetohearwhetherourapproachhasbeenvaluableornot.

WeencourageyoutogetintouchwithJontyRoland([email protected])toletusknowyourthoughtsonourfindingsandhowyouusethemtodrivemoreefficientservicesinyourorganisation.

TheNHSfacesthemostprolongedperiodoffinancialconstraintinitshistory.Inthenextfouryearsitneedstofind£15–£20billionofsavingsatthesametimeastacklingunderlyingincreasesinthecostsanddemandforhealthcare,andmanagingoneofthebiggestreorganisationsinitshistoryaswell.

Numerousinitiativesareunderwaytotrytoidentifywheremoneycanbesaved,yetfeedbackwereceivedsuggestedthatveryfewofthemwereengagingdoctorsinanymeaningfulway.ItisclinicianswhocommitmostoftheNHS’resourcesandfeelresponsibleforthecaregiventoindividualpatients.

Thepremiseofthisprojectisthatwhenchangeneedstohappenrapidly,inevidence-basedandhighlysensitivefields,itisbesttoasktheexperts:thosewhoprovidetheservicesfirsthandandseeboththevalueandthewastemostdirectly.

Wethereforedevelopedaverysimplemethodology:toassemblegroupsofdoctorsfromaseriesofspecialtymedicalsocietiesorRoyalCollegesandinhalf-dayworkshopsaskeachofthemtoanswerthefollowingquestion:

“How can practitioners in your specialty help to release NHS resources while maintaining or enhancing quality?”

Theywereaskedtodrawontheircombinedexperienceandknowledgeoftheevidenceintheirspecialty,butalsoencouragedtomakecreativesuggestionsbasedontheirexperience.

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How to read this reportbulletpointstyle,andshouldbereadassuch,whilesomehavebeenexpandedintofullprose.Wearesatisfiedwiththisdiversitybetweenthespecialties,astohomogenisethemwould,webelieve,havelessenedtheirpower.Ithasalsoallowedeachchaptertocoveraverybroadrangeoftopicsinasmallnumberofwords.

Weadviseyoutoreadthisreportasatooltoguideandinformthediscussionsaroundcostefficiencyweknowtobetakingplacelocallyandnationallyalready.Wehopethatwithitthesediscussionscanbenefitfromgreatercollaborationbetweenmanagersandcliniciansandcanprotect–perhapsevenimprove–qualityofcareduringthedownturn.

Inproducingthefollowingchapterswehaveattemptedtohaveaslittleauthorialinputaspossible.Wewantedtotransmittheexpertiseoftheparticipantsfromeachspecialtyinaspureaformaswecould.Ourroleinthefocusgroupswastofacilitateandrecordthediscussion,afterwhichwesenttheparticipantsasummaryoftherecommendationsthatweremade.Eachgroupthenengagedinaniterativeprocessofdebatingandamendingtheirsummaryviaemailuntiltheyweresatisfiedwiththefinalproduct.

Asaresultofthisprocess,thechaptersdonotfollowasetformat,butvaryconsiderablyinform,lengthandstructure.Someremainina

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NeurosurgeryThe following recommendations were produced by the British Society of Neurological Surgeons to highlight where resources could be released in NHS neurological services, while maintaining or enhancing quality.

neurosurgeon).Theseteamsmeettorapidlyreviewthelistofreferralstoaneurosurgeryunitand,onconsideringtheGP’snotesandanyscansthathavebeeninitiated,decidewhethertoaccepttheappointmentdatethathasbeenmadeorwritebacktostatewhy–onthestatedsymptoms–aspecialistappointmentisnotnecessary.

Someareashaveencounteredproblems•withthisinnotbeingabletorejectappointmentsmadeunderChooseandBook.Onewayaroundthisistoarrangedummyappointmentsthroughtriage,andthesecanbeacceptedorrejected.

AsimilarsystemtotheabovecouldbeusedforvettingGPs’accesstoimaging,withasmallpanel,includingaconsultantneurosurgeon,quicklyreviewingthenacceptingorrejectingreferralstoMRIorCTscans.

Alternatively,furthereconomiescouldbemadebyusingaprimarycare-basedtriagesystem,wherebyunlessaspecialistopinionisspecificallyrequestedalessqualifiedindividualthanaconsultantneurosurgeonmakesdecisionsonreferralsbasedonmutuallyagreedguidelines.

Locallyobservedimpactsofintroducingsuch•asystemincludeasubstantialimprovementintherateofpeopleseenbyaneurosurgeonwhowentontobeoperatedon.

Thereisahighincidenceofunnecessaryreferralfromjuniordoctorsduringnightshifts.Nationalprotocolsforjuniordoctorsonwhentorefertoaconsultantneurosurgeoncould

Themes

Referral•

Pre-admission clinics•

Emergency admissions•

Discharge•

Follow-up•

Procurement•

Single-use items•

Culture•

Reduction of changeover time in theatres•

Other areas of variation in practice that could •be harmonised

System-wide issues•

Referral

Thereareasignificantnumberofunnecessaryreferralsfromprimarycaretoneurosurgicalunits.

Therearemethodsoftriagingavailablethatwouldmakereferralmoreefficient.

SomeneurosurgicalunitshavesetclearreferralcriteriainpartnershipwiththeirPCTsandlocalGPswiththeeffectofreducingunnecessaryreferrals,yetthisisnotconsistentlypracticedacrossthecountry.

Anothertechniquethatisused,whichiseffectivebutnotuniversal,ismulti-disciplinarytriageteams(whichincludeaconsultant

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bedevelopedwiththesupportoftheBritishSocietyofNeurologicalSurgeonsandusedtoreducethiscostandincreasethequalityofcare.

DistrictgeneralhospitalsnotperformingMRIsatnightisarelatedcauseofunnecessaryreferraltoneurosurgery.AhighpercentageofurgentMRIsarenegative,showingthereisscopetoreducethenumberbeingtransferredtoneurosurgicalunits.

Fromasystem-wideperspective,thelackofanationalimagetransfersystemcreatesunnecessarywastageoftimeandresources.Thisisparticularlythecaseinneurosurgeryasitisaheavilyimagedependentspecialty.

Pre-admission clinics

Goodpre-admissionclinicsreducethenumberofcancellations,complications,delayeddischargesand,ultimately,lengthofstay.

Goodpracticeinpre-admissionisnotuniversal,sothisneedsre-emphasising,perhapsbasedaroundthefollowingfourfactors:checkingtheindicationissensible;ensuringthepatientissafetoundergoanaesthesia;makingsurethatallthelogistics(includingcorrectkit)areinplace;andensuringthereisthoroughdischargeplanning.

Betteradherencetobestpracticeinpre-admissioncouldbesupportedeitherbytheproductionofachecklistand/orbyaspecialistnursebeingassignedtomicro-managethekeyfactorsabove.

Thecoreaspectsofpre-admissionclinicplanningcouldbedoneoverthephonemoreoftenthaniscurrentlythecase,savingjourneysandtime.

Thereisaneedtoensurethatthosedoingpre-admissionclinicsaresufficientlysenior,whichshouldhavetheeffectofreducingon-the-daycancellations.Thepossibilitycouldevenbeexploredofhavinganaesthetistsleadtheclinics,asispracticedinpartsoftheUSA.

Cleareraccountabilityisneededforthecheckingofbloodresults.Thepre-admissionclinicshouldberecognisedasprimarilyresponsibleforthis.

Emergency admissions

Separatingemergencyoperationsfromelectiveoneswouldallowsmoother,moreefficientrunningofelectivelistswithoutinterruptions.

MoreflexibilityinthelengthofworkingdaysandSaturdayworkingwouldallowgreateruseofavailablefacilities.However,thiscouldonlybedoneafterinvestigatingwhetherincreasedstaffingcostsmightunderminethesavingsthiswouldachieve.

Ofthemselves,suchchangeswon’tsavemoney,butgiventhatthefinancialcrisisisprimarilydrivenbyrisingdemandandcostsratherthanareductionincash,suchchangescouldsavefurthercapitalexpenditurelateron.

Discharge

Gettingpatientsdischargedwellisasignificantchallenge,andadriverofconsiderableunnecessarycost.

Publishingexpectedlengthsofstayforparticularconditionswithinaunitwouldgiveallstaffanunderstandingofwhattoworktowards.Thiscouldevenbeexpandedtosomethingencompassingmanyunits–orevennationally–toallowbenchmarking.However,if

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usedonawiderscaletherewouldhavetobeagreaterdegreeofflexibility(intheformofastandarddeviation).

Specificdischargedatescouldbeagreedforindividualpatientswhentheyareadmitted.Allstaffontheunit(andthepatient)wouldknowtheseandbeexpectedtoworktowardsthem.Theprocesscouldevenbetakenonestepfurther,withdetailedcareplanningforeachpatientstatingwhatshouldbehappeningeverydayfromthefirsttothelastdayofstay.

Theuseof‘departurelounges’cancreatemoreefficientuseofbeds.Theseareroomswherepatientscangofrom8amontheirdayofdischargesothattheirbedismorerapidlyfreedup.

Follow-up

Repeatedfollow-upsandin-personfollow-upappointmentsareoftenunnecessaryusesoftime,moneyandtravel.

Morefollow-upcouldbedonebytelephone,whereappropriate.

Perhapsastandardofonepost-surgicalvisitfollowedbyphonecontactcouldbeagreed,unlessanindividualsurgeoncandemonstratetopeerswhytheywishtovaryfromthisnorm.

Morefollow-upcouldbeledbyphysiotherapistorspecialistnurses.

Procurement

Shunts–itisestimatedthatbetweentenand15modelsarecurrentlyinuseamongstneurosurgeons,yetbeyondprogrammableversusnon-programmablethereisno

evidencethatoneisbetterthananother.Ifstandardisedtoasmallnumbertheycouldbeprocuredmorecheaplyandwithnoadverseeffectonquality,solongasvariationfromthiswaspermittedifitwaspartofatrial.

Spinalimplantsvaryhugelyinprice–from£500to£10,000–yetitisquestionablewhethertheyarenecessaryatalland,eveniftheyare,whethertherangecurrentlyinuseneedstobeaswide.

Thereisalsoscopetoreducethenumberofinstrumentsthatarepurchasedas,inreality,therearemoreavailabletothesurgeonthanareused.Consultant-levelinvolvementindecisionstocloneparticularinstrumentscouldreducethis.

Somedevicescouldberemovedfromtheatrealtogether.Evidenceshowsthereisalowerriskofinfectionfromsuturescomparedtostaples,yetstaples–whichcostmore–arestillinhighlevelsofuse.Theoptionshouldberemoved,atleastforsmallwounds.

Single-use items

Themodelsusedtoassesstheriskofprioninfectionfrominstrumentsarenon-evidence-based.Theyarefoundedonestimated,notionalrisksthatsinceimplementationhavesubsequentlybeenreviseddown.Yettherehasbeennochangeinthepolicy.

TheseregulationsareonlypracticedintheUKanddriveunnecessaryuseofexpensive,single-useitems.

ThecostsofcurrentprocedurestominimiserisksofCJDinfectionare,therefore,disproportionatetothesizeofthatrisk.

Thecurrentregulations,eveniftheywere

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justified,areunfeasibletoimplement–particularlyinstrumenttracking.

Culture

Increasedteamworkinginrecentyearshashadapositiveeffectonimprovingconsistencyofpracticebetweenindividualneurosurgeons.

Thereis,however,aprevalentcultureofacceptingwasteinthetheatreenvironment.Thereneedstobearealisation,fromconsultantsthroughtotechnicians,thattheirbehaviourandhabitsdirectlyaffectthebudgetaryhealthoftheirunit.Neurosurgeonscouldsupportazerowastemessageacrosstheunit,hospitalandtrust,perhapsaspartofawidernationalinitiative–“Youwouldn’tacceptwastelikethisathome!”.

Reduction of changeover time in theatres

Inadequatesupportforanaesthetistsisoneofthemajorcausesofdelays.Thissupporthasworsenedoverthelastdecade.

Theregulationthatanaesthetistsarenotallowedtofunctionwithoutanoperatingdepartmentpractitionerpresentisunnecessaryandcausesfrequentdelays.

Moreefficientporteringarrangementswouldallowforearlierstartsandfasterchangeovers.

Anothermajorcauseoftheatredelaysisnotstructuralorprocedural,however,butcultural.Thementalityofoperatingtheatresispermissiveoflateattendanceanddelays.Neurosurgeonsshouldseektocombatthis,bothintheirownhabitsandintheirleadershipoftheatreteams.

Other non-evidence-based areas of practice that could be harmonised

ThefrequencyofMRIscansforfollow-upoftumoursisvariable.Aneffectivemodelmaybeavailable,whichcouldbedisseminatedthroughneuro-oncologycancernetworks,reducingthefrequencyforsometumourtypes/agesofpatient.

Whom,whenandhowoftentoscreenforfamilialaneurysmsvariesunnecessarily.InputfromtheBritishSocietyofNeuroradiologistscouldhelpwiththis.

Bestpracticeinpost-coilingradiologyfollow-upcouldbeclarifiedwithinputfromtheNeuro-InterventionalGroup.TheremaybeinformationfromtheISATfollow-upstudywhichcouldinformauniformpolicythatiscost-effective.

Outpatients

Itispossibletodesignfacilitiesforoutpatientsthataremoreflexibleandallowgreaterefficiency,particularlyintheuseofbedsandwithtransfersbetweenoutpatientsandinpatients–forexample,day-caseunitsforinvestigationssuchasangiogramsandminorsurgery,oralternativevenuesforwardattenders,shuntreprogrammingetc.

System-wide issues

Thecostofsimplesurgicaldevices(suchasscrews)couldbeloweriftheexcessivedegreeofregulationaroundthemwasremoved.

Ifincentivescouldbedevisedtogivecliniciansmoreofastakeandinvolvementinthefinancesoftheirunit,thiscouldhaveasignificantimpactonthecultureofwaste.

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Fromasystemsperspective,therearestilldelayscausedbysocialservicesnotbeingsufficientlyresponsive.Therewassupportforasystem,inplaceinsomelocalities,wherebythecouncilpaysforanyadditionalcosttothehospitalfromdelayeddischargepastacertaindelay.

TheEuropeanWorkingTimeDirectiveisamajorcauseofwasteandchaotic

Workshop participants

Mr Paul Eldridge, SBNS Hon. Sec and consultant neurosurgeon in Liverpool

Mr William Harkness, SBNS Council Member and consultant paediatric neurosurgeon (GOS)

Mr Philip van Hille, Immediate Past President, SBNS, and consultant neurosurgeon, Leeds

Mr Alistair Jenkins, SBNS Council Member and consultant neurosurgeon in Newcastle

Ms Anne Moore, SBNS President and consultant neurosurgeon in Plymouth

Prof John Pickard, Professor of Neurosurgery in Cambridge

Mr Owen Sparrow, Chair of SAC in Neurosurgery and consultant neurosurgeon in Southampton

practices,particularlythroughhavingtouseconsultant-deliveredservicesovernightforconditionsandproceduresthatdonotrequirethatlevelofexpertise,makingthemlessavailableforspecialistworkinthedaytime;andalsoinincreasedtimespentonhandoversthatareineffective.

Morerapidemergencypatienttransportationwouldreducepatientmorbidity.

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GeriatricsThe following recommendations were produced by the British Geriatrics Society (BGS) to highlight where resources could be released in NHS geriatrics services, while maintaining or enhancing quality.

Prior discussions had already taken place between the England Council and the UK Management Committee of the BGS, whose ideas fed into this meeting.

whichparticularkindsofpatientscouldbeimmediatelytriaged.

Theservicewouldbeforfrailolderpeopledisplayingsignsoftypicalcomplexco-morbidities.Triagecriteriawouldnotbeage-basedandwouldnotdivertthosewithsevereconditions(suchaschestpainorfracturedneckoffemur)totheteam.

Theteamwouldhavecloselinkstocommunitycarecolleaguessuchasintermediatecarenursesandwouldaimtogetpatientssupportedtogohomemuchmorequicklythanhaspreviouslybeenpossible.

Thiscouldeitherbeimplementedasaninvest-to-savescheme,meaninghighercostsintheshorttermtorealiselowercostslateron,or,giventhestrengthofevidenceofpositiveoutcomesfromsimilarmodelsinternationally,1couldbereconfiguredfromexistingresourcesinlargerdepartments.

‘Best buy’ 2: People should not go into permanent care without a comprehensive geriatric assessment by a team led by a geriatrician and, where possible, done in the community

Thenumberofpeoplegoingpermanentlyintocarehomesisunnecessarilyhigh.Asthisisaveryexpensiveoptionforpublicservices,thereneedstobeproperpolicingtoensureappropriateplacement.

Comprehensivegeriatricassessments(CGAs)offerthepossibilityoffindingmorecreativeways

Themes

‘Best buy’ 1: A geriatrician-led team at •or near the front door of every admitting hospital

‘Best buy’ 2: People should not go into •permanent care without a comprehensive geriatric assessment by a team led by a geriatrician and, where possible, done in the community

‘Best buy’ 3: Advance care planning•

Medicines management•

Recognition and treatment of delirium•

Virtual clinics and telephone consultations•

Frequency and expense of litigation•

Integration•

More efficient working practices•

Other examples of best practice•

‘Best buy’ 1: A geriatrician-led team at or near the front door of every admitting hospital

ThereisanincreasingnumberofolderpeoplepresentingtoA&Edepartments,someofwhomaredischargedwithouttheirunderlyingproblemidentified,andsomeofwhomareadmittedbutkeptwaitingunnecessarily.

Ratherthanwaitinguptofourhourstoseeajuniordoctor,aspecialistteamledbyageriatrician(andpreferablyinaphysicallyadjacentunit)couldbeonhandandto

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tosupportpeopletocontinuelivingathome,yetarenotroutinelyperformedpriortocarehomeadmission.

CGAsarecurrentlydoneinhospitals,butthisputsoffsomepeoplewhodislikethesetting.Establishingcentresincommunitysettings,suchascommunityhospitals,wherethiscouldbedonewouldincreasethenumberofpeoplecomingforward,reducingthenumberadmittedtoresidentialandnursinghomecare.

Anycostgeneratedbythiscouldberecoupedfromthereallocationofintermediatecarebudgets,whicharesub-optimalinmany,thoughnotall,areas.

Whileitiscurrentlyunclearexactlyhowthiscouldwork,securingcloseinvolvementfromGPconsortiawouldbebeneficial.Thismightbeanearlyareaforconsortiatoconsidercommissioningininnovativeways.Ensuringadequatespecialistinputfromgeriatriciansinthisisimportant.

‘Best buy’ 3: Advance care planning

Thisisanexampleofbestpracticethatisnotyetroutineamonggeriatricians.

Advancecareplanninginvolvestabulatinginformationaboutthepatient’swishesonappropriatenessofadmission,investigation,intervention,rehabilitationandendoflife.Thisinformationisstoredinawaythateverybodyhasaccessto.Palliativecarecolleagueshavealreadydonemuchoftheworktodevelopthismodel.

Thiswouldensurethatresuscitationwouldnotbeattemptedincaseswhereitisinappropriateandagainstthepatient’swishes.

Itwouldalsoreduceinappropriateemergencyadmissions,toomanyofwhicharegeneratedbyacarehomenotknowingtheperson’swishes,

callingtheout-of-hoursserviceandleadingtoahospitaladmission.Insomecasesthiscanleadtosomeonespendingtheirfinalhoursinhospitalratherthanathome.

Theprocessofhowtobuildadvancecareplanningintotheexistingpathwayneedssomemorediscussion.Isdischargeplanningtherighttimetohavesuchconversations,oristheclinicafterwardsbetter?Eitherway,itisimportantthatanexistingrelationshipisinplace.

TheBGS’roleinthiswillbetoencouragetheuptakeandspreadoflearningamongstitsmembers,andtoworkwithleadersinthecarehomessector,wherethebiggestopportunitiesforimprovementexist.

Other recommendations for more effective use of resources

Medicines management

Itishopedthattheadventofelectronicprescribingwillreducethenumberofadverseeventsduetodruginteractions.

Amoreimmediateopportunityexiststoreducesomeofthemorecommoninappropriateprescribingerrorsthataremade,throughazerotolerancedrivetowardsdrugrecording–alldrugchartsmustgiveastopdateforadrug,andallmuststatethepatient’sallergies.

Theproblem,intheviewoftheBGS,isnotalackofpharmacologyknowledge,butalackofbasicsystemstosupportpractice,andlaxadherencetopracticesthatdoexist.

ThedevelopmentbytheRoyalCollegeofPhysiciansofanationaldrugchartisstronglysupportedbytheBGS,andtheBGSwillendeavourtobackupitsimplementationbydisseminating

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aculturefromthecentrethatitisunprofessionalnottorecordmedicationproperly,includingastopdate.TheBGScallsonemployersandregulatorstojoininwiththisaswell.

Thesechangeswouldreducecostsboththroughaloweroveralldrugsbillandthroughreductioninmedicationerrorsleadingtotheneedforfurthertreatment.

TheBGSisalsosupportiveofsystemssuchaspatientpassports,whichwouldenablerecordsonapatient’smedicationandallergiesandasynopsisoftheirmedicalproblemstobeobtainedinamoretimelyfashion.

Recognition and treatment of delirium

Deliriumispoorlyunderstood,oftenunrecognisedandinadequatelymanagedinhospitals,yetitisasignificantfactorinextendedlengthsofstayandmortality.

Simplemeasures,ifmorewidelyused,wouldpreventmanycasesofdeliriumoccurring.AnongoingstudybyHoltandYoungisdemonstratingsuccessfulresultsfromtraininghealthcareassistantsandwardnursestorecogniseandpreventdelirium.

ThiscouldbepackagedasabestpracticepublicationbadgedbytheBGSanddisseminatednationally.TheBGShasproducedclinicalguidelinesondelirium,whichinclude76keyreferences.TheseareavailableontheBGSwebsite(www.bgs.org.uk)under‘Clinicalguidelines’(Clinical guidelines for the prevention, diagnosis and management of delirium in older people in hospital).

Virtual clinics and telephone consultations

Thesearebestforpeoplewithsinglesystemproblems,forexamplediscussingcarotiddopplerresults,ratherthanforpatientswithmulti-systemdisordersandfrailty.

Frequency and expense of litigation

GeriatricianscouldmakeacontributiontoreducingthelitigationbillintheNHSbybeingmoreawareofthemaincausesofpay-outs.TheBGSwillthereforeproduceapostcardadvertisingthetoptenreasonsfordefenceclaimsingeriatricsanddisseminatethistoitsmembers.

Integration

Whilenotadirectcostsaving,therisksaroundforthcomingverticalintegrationsintheNHSinEnglandmaydriveincreasedcosts.TheBGScouldthereforeproduceaguidetowhatworkswellforolderpeoplewhenintegratingvertically.

InseekingtoimproveGPskillsandcontinuityofcarebetweengeriatricsandprimarycare,geriatricianscouldconsiderresurrectingoffersofdomiciliaryvisits.Thesewouldhelptoreduceunnecessaryadmissions,althoughunlikeinthepasttheyshouldn’thavefinancialincentivesattachedtothem,andtherewouldneedtobeclearstandardsonwhentheyshouldbeused.Iffounduseful,domiciliaryvisitscouldevenbegivendedicatedtimeinthegeriatrician’stimetable.

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More efficient working practices

Hospitalworkingisstillsometimesconfiguredarounda9to5,fivedaysperweekmodelthatisnolongersustainablewiththelevelof24/7demand.TheBGSrecognisestheneedforthismodeltochange,andbelievesthatgeriatricianswillplaytheirfullpartalongsideotherspecialtiesinsupportingthistransition.

Other examples of best practice

Rapidaccessclinics,forexamplefortransientischemicattacks(TIA)–theseexistandarecost-effective,butarenotuniversal.

Interdisciplinaryteams–geriatriciansshouldreviewtheskillmixoftheseteamsasinmanyareasthediversityhasbeensignificantlydiminished.Thisisoneofthedriversofunnecessarilylonglengthofstay.

Inrecentyearsgeriatricianshavemadesignificantprogressexportingtheirskillsinthecareofolderpeopletoorthopaedicsurgeons.TheBGSnowintendstoattempta


Dr Ian Donald, BGS member

Prof Graham Mulley, Immediate Past President

Dr Mehool Patel, BGS member

Dr Linda Patterson, BGS member

Dr Tarun Solanki, BGS member

similarapproachtootherdisciplinesofsurgery.Throughthisproject,alinkwillbeestablishedwiththeVascularSociety.

Therearepresentlyfewopportunitiesforgeriatricianstobenchmarktheperformanceoftheirdepartmentsagainsteachother.Usefulmeasurescouldincludethenumberoffallsinhospitalorthenumberofpatientswithdiarrhoea.Discussionsareongoingnationallyaroundestablishingclinicaldashboards,andtheBGSissupportiveofthese.TheBGSisalsosupportiveofthemovetowardsoutcome-focusedmeasures,andhasalreadydevisedsomeoutcomemeasuresforgeriatrics,whichitwillbeginpromotingandwhichhavebeenincludedinitsresponsetotheconsultationonoutcomemeasures.

References

Caplanetal:‘Arandomised,controlledtrial1.ofcomprehensivegeriatricassessmentandmultidisciplinaryinterventionafterdischargeofelderlyfromtheemergencydepartment–theDEEDIIstudy’,J Am Geriatr Soc.2004Sep;52(9):1417–23.

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Vascular servicesThe following recommendations were produced by the Vascular Society to highlight where resources could be released in NHS vascular services, while maintaining or enhancing quality.

wouldgivethebenefitsofcostandqualitywhilemaintainingappropriatelevelsofaccess:

Highlycomplex,high-risk(andcostly)surgical1.procedureswouldbelimitedtofourorfivespecialisedunitsinEngland.Forsomeprocedures,suchascomplexendovascularaneurysmrepairs(EVARs),thiswouldbewithaviewtotheirrollingoutmorewidelyovertime.Others,particularlythoseoflowvolumeandhighrisk,suchasthoracoabdominalrepair,wouldremainlimitedtotheseveryfewcentres.

Proceduresofmediumcomplexity,such2.asinfrarenalaorticaneurysms,carotidendarterectomy,lowerlimbrevascularisationandamputationsforlimbischaemia,wouldbedonein40to50vascularunitsnationally–afurtherhalvingofthecurrentnumber.Theseunitswouldoffera24/7servicebasedaroundeighttotenconsultantseach.Protocolsandqualitytargetswouldbesettoensurethatallpatientsservedbyanetworkreceivedequalandtimelyaccesstothecaretheyneed.

Proceduresoflowcomplexity,suchas3.diagnosticultrasoundandcross-sectionalimaging,angiography(someangioplasty),varicoseveinandvascularaccesssurgery,wouldbeprovidedinmosthospitals.Inaddition,clinicswouldberuninallhospitalswithineachnetwork.Inthiswaythecentral(hub)hospitalwouldprovideservicesinanoutreachmannertosurroundinghospitals.Thecentrewouldhaveresponsibilityforcaredeliveryagainstagreednationalandlocalservicelevelagreements.Thiswouldresultinmostpatientcontactwith

Themes

The structure of vascular services nationally•

More consultant-delivered care•

Discharge planning•

Demand management•

Outcome-based standards•

Procedures of low or questionable value•

Theatre overruns•

Procurement•

The structure of vascular services nationally

Manyunnecessarycostsinvascularsurgeryderivefromextendedlengthsofstay.Reducingtheserepresentsaclearareawherecostefficiencyandqualitycanbeimprovedsimultaneously.

Remodellingvascularservicesbyreducingthenumberofproviderswouldreducemortalityandmorbidityaftermajorvascularsurgerybyconcentratingmedicalandnursingexpertise,increasingunitvolumesanddrivinggreatersystematisation.Thecostsinvolvedinthecentralisationofserviceswouldbeoffsetthroughimprovedoutcomesbyreducingthecostofpost-operativemorbidityandhencelengthofstay.

AfirstphaseofremodellinghasalreadyresultedinthenumberofvascularunitsinEnglandbeingmorethanhalvedtojustover100.

Thisremodellingneedstocontinueintoafurtherphase,leavingathree-tiersystemwhich

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vascularservicesoccurringintheirlocalhospital,neartotheirhomes.Thepatientwouldonlytraveltothecentreforcomplex,hightariffinterventions.Staffingofoutreachservicesmightuselocallybasedstaffunderthesupervisionofspecialistsfromthecentre,ensuringlocaldeliveryoftraining.Thiswouldalsoestablishlinksattheclinicallevelbetweenthecentreandoutreachservices.

Anadditionalbenefitofthisthree-tiermodelisthatvascularsurgerywouldmapmuchmorecloselytothecurrentstructureofcardiacsurgery.Giventheoverlapbetweentheseareas,therewouldbescopetoshareinfrastructureinfuture,resultinginamoreefficientuseofresources.Theintroductionofhybridtheatresisoneexampleofgoodpracticeinthisarea.

RealisingthisremodellingwillrequiretheVascularSocietytointensifyitseffortsinsettingouttoitsmembersthebenefitsofmovingtothisnewsystem.TheVascularSocietywillneedtodescribehowworkinginbiggerunitswillimproveefficiencyandpatientsafetywithoutcompromisinglocalhospitalcaredelivery.TheVascularSocietywillneedtosecurethesupportofhealthleaderstoreassuresmallerhospitalsthatitwon’tleadtotheirlosingoutontheirabilitytoperformothersurgicalproceduresthatrequiresupportorinputfromvascularsurgery.

Anotherchallengeistoproduceastructureforthetrainingofjuniordoctorsthatmapstothisnewmodel.TheVascularSocietywillbehappytocontributetodevelopingthis.

More consultant-delivered care

Thereisscopetoimproveworkingpatternsinvascularsurgeryunitstomakebetter

useofexistinghumanresourcesandmaptheprovisionofservicesmorecloselywithpatternsofdemand.Inparticular,makingmoreeffectiveuseoftheconsultantsinunitswouldbringbothcostandqualitybenefitswithoutneedingextrastaff.Examplesare:

takingoneconsultantperweekoutof•electivecareandontothewardtoberesponsibleforthewardround

patientmanagementtoenablerapid•dischargewhereappropriate

juniordoctortraining•

betterlistmanagementforurgentreferrals.•

Consultant-deliveredcarewillhelptoreducelengthsofstay.Inaddition,therewouldbeefficienciesaroundimprovedprioritisationofwork.Readyaccesstoemergencyoperatingtimewouldreducethewaitforsurgeryformanypatientsastherewouldbeanidentifiedspecialistavailabletoperformthenecessaryprocedures.

Everyvascularunitwilloperatea24/7consultanton-callrota.Theon-callteamshouldhavea24/7presenceinthecentralhospital,withclearwrittenprotocolsformanagingemergenciespresentingtootherhospitalswithinthenetwork.

Thereisaneedtodevelopspecialistteamworkingbetweenvascularspecialists,radiologistsandanaesthetiststoimproveefficiencyandpatientsafety.ThereisevidenceofgoodpracticeintheUKandthisshouldbemorewidelyadopted.

Betterplanningofhigherriskprocedureswouldallowbetterallocationofscarceresources(forexample,criticalcarebeds).Specialistsshoulddevelopcarepathwaysthatdescribehowcarewouldbedeliveredforthesecasesandhowpatients’needsforcriticalorhighdependencycarecanbebestmanaged.

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Discharge planning

Thereisaneedforthewidespreadadoptionofproperdischargeplanningamongstallvascularunits,includingconsultantinputintopre-assessmentanddischargeplanningmeetings.Improvedpre-assessmentalonecouldallowallpatientstobeadmittedonthesamedayastheiroperation,regardlessofitsseverity.

Theuseofsame-dayadmissionreduceslengthofstayandcanprovidesavingsinthenumbersofbedsneededtorunaservice.

Anothermodelthathaspotentialtobespreadmorewidelyistheestablishmentofprotectedbedstodrivehigherthroughputforcertainconditions.Protectedbedsforangioplastyhave,whereused,resultedinsurgeonscompletingagreaternumberofcasesperday.

Bedsoutsideoftheacuteunitforrehabilitationandlowintensitycarewouldalsohelptheappropriatelevelofcaretobedeliveredcost-effectively.

Demand management

Thereisaneedformoreproactivestrategiesbyvascularsurgeonstomanageoutpatientdemandforcommon,minorconditionssuchasminorvaricoseveinsandintermittentclaudication.Thiswillfree-upconsultanttimeformanagingmorecomplexproblemsinatimelymanner,whilemakingbetteruseofexistingresources.

CooperationbetweenlocalvascularsurgeonsandGPstodevelopandshareclearreferralprotocolsisoneofthemosteffectivewaysofmanagingdemand.

Oneunitthatdidthiswaseventuallyabletocloseoneofitstwowardsbecauseoftheextentofthereductioninoutpatientdemandthatwasachieved.

Outcome-based standards

Professionalstandardsareoneofthemosteffectivewaysofdrivingimprovementsinpracticeamongstvascularsurgeonsnationally,improvingqualityandcost-efficiency.AllvascularspecialistsneedtosubmitalloftheirindexcasestonationalauditusingtheNationalVascularDatabase.

Criticaltotheseisthedevelopmentofcarepathwaysthathaverobustoutcome(aswellasprocess)measures.Theseneedtobeco-producedwithpatients.TheVascularSocietyisintheprocessofdevelopingseveralofthese,andwillendeavourtousethemasameansofimprovingpatientsafetyandsatisfactionwithcare.

Procedures of low or questionable value

Thereareareasofclinicalpracticeamongvascularsurgeonsthatvaryunnecessarily,orwhereproceduresaredoneonthebasisoflimitedorquestionableevidence.Inthesecasesstandardisationcouldresultinlowercosts.

SeveraloftheseareasshouldbeconsideredprioritiesforfurtherupdatesofNICEguidelines.TheVascularSocietywillencouragevaricoseveinsinparticulartobereviewedassoonaspossible,basedonthehighvolume,andhencecost,oftheseprocedures.Currently,referralpracticesandinterventionratesvarywidelyacrosstheUK.

Intheinterim,theVascularSocietywouldbewillingtoproduceguidelinesonwhenvaricoseveinsurgeryshouldbeprovidedontheNHS.Therearesomecaseswhereevidenceshowsitisclinicallyandcost-effective(suchaswithpatientswhohavehadulcers)butcurrentlyaccessvariesinawaythatisnotrational.

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Alternatively,guidelinescouldbedrawnuplocally,assomelocalPCTs,GPsandvascularunitshavedonealready.

Theatre overruns

Feweroverrunsinsurgicaltheatreswouldresultinincreasedcapacityandgreaterefficiency.

Onewayofachievingthiswouldbetoextendthedurationoftheatrelists.Currenttimesarenotparticularlygoodforvascularsurgery,withfinishestypicallyscheduledaround4:30to5:00pm.Extendingthisto6:00pm–theso-called‘threesessionday’–maybebetter.

Staggeringthestarttimesoftheatresalsomaybemoreefficientandavoiddelays,aswouldgreateruseofweekendsforelectivework.

Whileoutsidetheinfluenceofvascularsurgeonsalone,theestablishmentofleaguetablesforlatestartsamongsurgeonsinaunithavebeenfoundtoimprovetheirkeepingtotime.Vascularsurgeonsshouldsupportsuchlocalmeasures

thatobserveandfeedbackbehaviourswhichimprovethepracticalaspectsofcare.

Procurement

Thereisscopeforincreasingeconomiesofscaleinprocurementthroughjointworkingbetweenvascularsurgeryandotherspecialties,particularlyasprovisionbecomesmoreconcentrated.

Sharedprocurementwithcardio-thoracicsurgeryinparticularshouldbeexploredbysurgeonslocally,particularlyaroundhybridtheatres,high-endimagingandanaesthesia,aswellasnursingandcriticalcare.

Theover-regulationofbasicdevicesresultsinveryhighcostsforrelativelysimpledevicessuchasendovascularstentgraftsforaorticaneurysmrepair.Thereispossiblysomescopeforvascularsurgeonstoagreetofurtherlimitthenumberofthesedevicesavailable(althoughtherangeisalreadyfairlysmall)orformanufacturerstoagreetoasetprocedurepriceinordertocontinuesupplyingtotheNHS.


Professor Jonathan Beard (Consultant vascular surgeon, Sheffield)

Mr John Brennan (Consultant vascular surgeon, Liverpool)

Professor Nick Cheshire (Consultant vascular surgeon, Imperial)

Mr Jonothon Earnshaw (Consultant vascular surgeon, Gloucester)

Mr Ashok Handa (Consultant vascular surgeon, Oxford)

Miss Linda Hands (Consultant vascular surgeon, Oxford)

Mr Richard Holdsworth (Consultant vascular surgeon, Stirling)

Mr Peter Lamont, President of the Vascular Society (Consultant vascular surgeon, Bristol)

Mr David Mitchell (Consultant vascular surgeon, Bristol)

Professor Cliff Shearman, Immediate Past President, the Vascular Society (Consultant vascular surgeon, Southampton)

Mr Mike Wyatt (Consultant vascular surgeon, Newcastle)

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PathologyThe following recommendations were produced by the Royal College of Pathologists to highlight where resources could be released in NHS pathology services, while maintaining or enhancing quality.

inManchesterinJune2010.Theopeningtopicwas‘ThechangingNHSenvironmentandtheimpactonpathology.’Aninteractivequizshowedthatover50percentofthelabmanagersattendinghadnotheardofQIPP.

TheNHSConfederationcontactedtheCollegeinJanuary2010tosuggestthattheorganisationsworktogetherwithotherhealthcarepartners.Afocusgroupwasheldon24August2010toexploretheexistingareasofreformingactivity,progresswithimplementationandidentifywherefurtherworkwasneeded.

Intheinterim,andinanticipationofthecoalitiongovernment’swhitepaper,Equity and excellence: liberating the NHS,theCollegepublisheditsownstatementonpathologyservicereconfigurationinJuly2010.1

Severalthemesemergedfromthegroupwhichmeton24August.

Intelligent requesting

“Ifwecouldstopdoingunnecessarylaboratorytests,wecouldatastrokemakeefficiencysavingsthatareprobablygreaterthanthosethatarecurrentlybeingdemanded.However,toooftenlaboratoriesfinditeasiertodoatestthantoarguethatitisnotnecessary.”1

In‘defaulttesting’,tick-box-stylerequestformsnudgeclinicianstowardsdoingmoreteststhanisnecessaryandencourageahabitoftickingalltheboxeswithoutthinking.Someteamsevenpre-prepareformsinadvancewithalltheboxestickedbeforeseeingthepatient.

Themes

Intelligent requesting•

Workforce profiles and training•

Efficiency and productivity•

Openness on performance•

New developments and molecular testing•

Intelligent commissioning•

Information technology and •disintermediation

Clinical leadership in pathology•

Who should do what?•

Background

TheRoyalCollegeofPathologistshasbeenhelpingtokeeppathologyprofessionalsinformedandinstepwithfinancialchallengesfacingtheNHS.ThisisparticularlyimportantgiventheprominencegiventoLordCarter’sreportsonNHSpathologyservicesinQIPP(Quality,Innovation,ProductivityandPrevention),withQIPPworkstreamsineverySHAledbytheSHAmedicaldirectors.InDecember2009,theassistantregistraroftheCollegewasgiventhetaskofprovidingalinkbetweenthePathologyClinicalDirectorattheDepartmentofHealthandtheCollege’sprofessionalmembershipinaddressingthefinancialchallengesaheadforpathologyinathoughtful,clinicallysoundandeffectiveway.

TheneedforlaboratorymanagerstobebetterinformedoftheQIPPagendawashighlightedataSiemens-sponsoredmeeting

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In‘activerequesting’,cliniciansmustwriteontherequestformtheteststheywishthelabtodo.Thisleadstosignificantreductionsindemand,withnonoticeableeffectonqualityofcare.

Alternatively,‘problem-based’requestingmodelsencourageclinicianstostatequestionsthattheywouldlikeansweredaboutthepatient,andthepathologistthendecideswhatteststhisjustifies.

InSalisbury,whenthereasonforrequesting•thyroidfunctiontestswasintroducedratherthansimplyrequestingthyroidfunctiontests,theuseofanalgorithmenabledanappropriateresponse.

Oneareathatusedthismodelsawa25per•centreductioninthenumberoftestsneeded.Italsoledtothereportsgeneratedbythelabbeingmorerelevantandcomprehensibletotheclinicianastheyansweredthequestionposed.

Therearealsospecificissuesaroundtheoveruseoftestingbydoctorsintraining,forwhomitisoftenamedicalcrutchwithtestsperformed‘justincase’whenthedoctor’sknowledgeoflaboratoryinvestigationisinsecure.Thereductionofbasicscienceandpathologyinmedicaleducationandtrainingneedstobeaddressedandreversed.Thisproblememphasisestheneedforanational‘formulary’oflaboratorytests,givingauthoritativeguidanceinamanneranalogoustotheserviceprovidedbytheBritishNationalFormularyfordrugs.ThiswasrecommendedbyLordCarterbutisstillunderdevelopment.

Duplicaterequestingforthesamepatientiscommon.Aneffectivewayofreducingthisistorequiretheuseofapatient’sNHSnumberinthetestingprocess,supportedbyITsystems

thatcanidentifyandflagduplicatetests;yet20percentofpathologylabsdonotroutinelyusetheNHSnumberandthereisfrequentlynocompulsiononrequestors.

OnelocalstudyofanA&Edepartmentfoundthat10percentofthetestresultsrequestedbyjuniordoctorswereneverlookedat.Thisisaclearareaofbothresourcewastageandpoorqualityofcare.Inbloodsciences,whereurgentcasesmaybeidentifiedatrequesting(ifITsystemsallow),thelabmaybeabletocheckwhetherahighpriorityresulthasbeenviewedafterareasonableperiodoftime.Ifthereisnorecordthatithasbeenaccessedwithinareasonabletime,theconsultantshouldbenotified.

Pointofcaretesting(POCT)hasenabledmoretestingtobedoneoutsidethelaboratoryinwaysthatmaybemoreconvenientforthepatient.Itisoftennotthecheapestoption,however,andthequalityofPOCTisvariable.ThereshouldbecompliancewithMHRArecommendationsintheuseofPOCT,includinglinkswithapathologylaboratorytoensureproperqualityassurance.TheCollegewouldsupporttheintroductionofamandatoryaccreditationschemetoaddressthispatientsafetyissue.Theevidenceonthecost-effectivenessandclinicalutilityofPOCTforsomeindicationsisunclearandwarrantsfurtherinvestigation,particularlyifitleadstoduplicatetestinginthecentrallabasclinicalcolleaguesarereluctanttotreatpatientsontheevidenceprovidedbyPOCTalone.

•Feedback of performance informationtorequestingclinicians,whetheritbeauditinformationabouttheirrequestingratesorinformationabouttheappropriatenessoftheirtestordering,hasbeenshowntoleadtomorerationalrequesting.

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Clinician education• canbelabourintensive,butiftargetedintheformofguidelinesorassociatedwithperformancefeedbackcanleadtomoreappropriatetestrequesting.1

ItwasoncecommonpracticeforlocallabstoproduceoccasionalreportstoGPsontheirrequestingratesbenchmarkedagainstothersinthelocality.Benchmarkreportswereaneffectiveandlow-costwayofrapidlychanginghighrequestingGPs’rates.Thereisaprogrammeindevelopmenttointroducethisnationally,andtheprogressofthisworkstreamneedstobeclarifiedanditsroll-outfullyfunded.ThestudyoftheprofileofpathologyservicesbyNHSLondonrevealedastrikinglydisproportionateriseinrequestsfromGPswhencomparedtotheriseintheacutehospitalsetting.Thereasonsforthisareunclearasyetbutworthfurtherinvestigation.

Anumberofpathologytestsnotuniversallyavailableinallpartsofthecountrycanbeusedinplaceofmoreexpensiveimagingtestsandareexamplesofevidence-basedclinicalpractice.Theimprovedqualityofcareresultingfrommanyofthesetestsincludesareducedneedforoutpatientappointments.NHStrustmanagersmaybereluctanttoacceptthisreductionbecausefewernewoutpatientappointmentsmeanalowerincomefromthatsource.Theirargumentfailsontwocounts:theoverallcostoftheservicerisesifpatientsarereferredforunnecessaryconsultationandprocedureswithoutreasonedselection;andpeopleareconvertedtodependentpatientsinappropriately.ExamplesincludeBNPforpossiblecardiacfailure(obviatestheneedforanechocardiograminmanycases)andfaecalcalprotectinforinflammatoryboweldisease(canavoidtheneedforcolonoscopyandexpensiveimaging).FiftypercentoflabsdonotofferBNPandveryfewlabsofferfaecalcalprotectin,despiteaNICEguideline.Labs

thathaveintroducedsuchtestshavemadeverysignificantsavingsfortheirhealtheconomies.However,asthesavingsarenotmadeinpathologyitisdifficultforpathologiststobuildbusinesscasesforimplementationunilaterally,especiallywherethesavingsrelyonareductioninactivityinanotherdepartment.

Wherelocalpathologistsareinregularandclosecontactwiththeircolleaguesintheacutehospitalandinthecommunity(GPsinparticular)theyareeffectiveinspreadingthiskindofbestclinicalpractice.Thisisrelativelylessdifficultinnon-metropolitanareasthaninourinnercitieswherethechallengeisgreater.InanygivenareaoftheNHS,however,itdoesrequiretheparticipationofmorespecialtiesthanpathologyandtheattentionandinterestofNHSmanagers.TheNHSConfederationandtheCollegewillpushmessagesactively,throughthisprojectandusingappropriatemediaoutlets,suchastheHealth Service Journal.2ThereisaclearneedtoworkcloselywithothermedicalRoyalCollegesandspecialtysocietiesinordertoagreemaximumorrationalrequestingforcommonconditionsandclinicalpresentations.Suchguidelinesdoexistbuttheirimplementationispatchyandinadequate.

Workforce profiles and training

“Alaboratorythathasinadequatelyskilledstaffcannotdeliveragoodservice.However,alaboratorythathasanexcessofskilledstaffcannotdeliveranefficientservice,andefficiencyisanimportantaspectofquality.

“Maintainingstaffskillsincludestrainingnewstaff.Organisationsthatchoosenottoemployandsupporttraineesmustnotbeallowedtoapplythispolicytogainacompetitiveadvantage,orthelong-termstabilityoftheservicewillsuffer.”1

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Somelabshavebeencreativeintheirapproachtoworkforcechangeswhileothershavebeenmoreresistant.Thereisaneedfortraditionalrolestochange,manualrepetitivetaskstobetakenonbystaffatlowergrades,andinnovationinlaboratorywaysofworkingtoreleasecostsavings.

Changesmustbeapproachedsystematically.Oneapproachthathasbeenusedtogoodeffectistheperformanceofa‘pertestaudit’.Thisinvolvesproducingabreakdownofthetasksrequiredforeachcommontest,workingoutwhichstaffcapabilitiesandstaffgradesarerequiredtodoeachofthesetasks,calculatingthecostperhourofthisandthereforearrivingattheoptimumstaffmixforaparticularlab.Thefocusofchangesshouldgenerallybeonthefunctionalityrequired,notonspecificstaffgroupswhichcanbeadistractionandleadtoinappropriateskillmix.

Laboratoriesshouldnotbetooreadilycriticisedforbeingriskaverseasthetime(andoftentechnological)investmentrequiredtoappraise,train,supportandcertificatechangesinworkforceshouldnotbeunderestimated.Workforcedevelopmentplansshouldbeforfivetoten-yeartimehorizonsandthesupportofpathologyandseniortrustmanagementmustbesustained.

Majorchangescannotbeimplementedintheshortterm,however.Theywillneedcarefulplanningasextendedrolesgenerallyrequiretrainingandappropriatebackfill.Moreimmediatechangesmaybepossibleoutsideofthelab.Someareashavesuccessfullytrainedhealthcareassistants(HCAs)inclinicsandonwardsinphlebotomyandPOCT.ThisdevelopmentrequiresHCAcapacitytosupportit,butcansignificantlyreducetheburdenonmoreexpensiveclinicians.ThecreationofmultifunctionalHCArolesenhancesmotivation

andflexibility.Nurse-ledanti-coagulantclinicsmakebetteruseofresourcesthanconsultant-ledbutarenotyetuniversal.Therearealsopatientself-testingschemeswhichhavepotentialfornationalroll-out.

Thereisuncertaintyabouttheplaceoftraineemedicalstaffasworkforceintheprovisionofpathologyserviceswhenfundingstreamsarebeingcutoratleastmodified,specialtytrainingnumbersarebeingcutorfrozen,thecommissioningandprovisionoftrainingprogrammesisbeingreformedinthemostradicalwayinthehistoryoftheNHS,andthefuturepositioning,structureandfunctionofpostgraduatedeaneriesisunclear.Similarly,theimpactoftheproposedchangesimplicitintheModernisingScientificCareersprogrammeontheavailabilityandutilityofbiomedicalscientistsandclinicalscientistsastheyprogressthroughtheircareerpathwayisalsounclear.Thislackofclarityneedstobeaddressedurgently.

Efficiency and productivity

“Ahigh-qualitylaboratoryservicemustbeefficient;otherwise,inaresource-limitedservice,itisusingresourcesthatcouldbenefitpatientsinotherways.Althoughtheargumentisself-evident,thisfactorhastoooftenbeenomittedfrommeasurementsofqualityintheNHS.

“Guidanceandprotocolsthathavebeendevelopedinthepastexclusivelyonthebasisof‘bestpractice’,withoutexplicitlyconsideringefficiencyorresourceuse,shouldbereviewedwithcost-benefitanalysisinmind.”1

Onanindividualbasisthereisvariationintherateatwhichconsultantpathologistsworkin

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termsoftestvolume.Someofthelowerratesareduetopathologists‘over-processing’byspendinglongeronindividualcasesthanisclinicallyrequiredorevenjustifiable.

Historicallyithasbeendifficultforlocalmanagerstoeffectivelychallengethisbehaviourbecausethereisnoconsensusaboutwhatareasonablecaserateis.The‘new’consultantcontractalsomakesaddressingproductivitydifficultsinceitstipulatestimespentatwork,notproductivityormeasurementofoutcomes.

TheRoyalCollegeofPathologistsproducedguidanceonHistopathologyofLimitedClinicalValue,withrecommendationstostopsome‘routine’examinations;3however,itisnotclearwhateffectthispublicationhashadinpractice,becauselaboratoriestendtocomplywithclinicalrequestsfortestingeveniftheclinicalneedforthetestisnotexplainedorjustified.

Whenprocessmanagementandsub-specialisationisintroducedinhistopathology,productivitymaybeimprovedalongwithquality.4

TheRoyalCollegeisengagedinare-analysisoftheCollegeworkloadunitsithaspublishedforhistopathologyandthisshouldassistintheconsiderationofadequatecase-rateparameters.ItisacknowledgedthatsomeCollegeguidelineshaveresultedinanincreaseinworkloadwithinhistopathologylaboratoriesinanattempttoimprovequalityandthatproductivityandefficiencymayhavebeensecondaryconsiderations.

Inallpathologydisciplinesefficiencyandproductivityarenotjustaboutwhathappensinthelab,orevenpre-selectionandpost-resultinterpretation.Muchpathologyclinicalconsultationconcernsdiscussionwith

non-laboratoryprofessionalsaboutpatientmanagementasadirectconsequenceoftheinterpretationofaresult.TheessentialnatureofthisconsultationismostobviousintheworkofthehistopathologistandthejointworkingoftheCalmanCancerMDT.Itisonlyslightlymoresubtleinotherspecialtiesbutitisdifficulttoseehowotherdoctorscanworkassafely,effectivelyandefficientlywithouttheguidingopinionsandadviceoftheirlocalchemicalpathologist,haematologistormicrobiologist.Takenforgranted,andneverobjectivelystudiedormeasured,thisisaninvaluableexpertresourcetotheNHS.

Openness on performance

“Theonly‘real’testofthequalityofamedicallaboratoryserviceisitseffectonpatientoutcomes.Anythingelseisasurrogatemeasure.Directmeasurementofaneffectonoutcomesisrarelypossible,sosurrogatemeasureshavetobeused,buttheirlimitsmustbeunderstoodandasuitablespreadofmeasuresisessential.”1

TheCollegewelcomesmovestodeviselaboratorykeyperformanceindicatorsandmakethesepubliclyavailable.Transparencycanbeausefultoolinimprovingvariousaspectsofthequalityandefficiencyofcare,andpublicationoflaboratoryexternalqualityassuranceschemeresultsisoneexampleofsuchtransparency.

WherelaboratoryExternalQualityAssessment(EQA)dataaremadepublic,theCollegewillworktosupportthisandtomakesurethatinformationisreleasedinaformthatisasmeaningfulandcomprehensibleaspossible,allowingcommissionerstomakebettercomparisonsoflaboratoryperformance.However,itiswastefultodemandanalytical

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accuracythatisfarinexcessoftheaccuracythatisneededinclinicalpractice,sotheCollegehasestablishedaprojecttoattempttodefineMinimumAnalyticalPerformanceStandards(MAPS).

Someexternalqualityassuranceschemes,especiallyinhistopathology,assessindividualpathologistperformanceratherthanoveralllaboratoryperformance.Thisisrelevanttomedicalrevalidation,butmaynotbeameaningfulmeasureofoveralllaboratoryqualitybecausedifficultcaseswouldnormallybesubjectedtointernalconsultationbetweenpathologists.CareisthereforeneededintheinterpretationofEQAdata.

TheCollegeissupportingon-goingworktodevelopstandardisedoutcomes-focusedmetrics.TheCollegeandDepartmentofHealtharesupportinganumberofworkstrandsonstandardisation–MinimumAnalyticalPerformanceStandardsfortests,HarmonisationofReferenceRangesanddevelopmentoftheNationalLaboratoryMedicineCatalogue(standardisationofnamesofanalytes,coding,unitsofmeasurementandsuitabilityforcombinationfromdifferentsources).Thecataloguewillultimatelydeliverthe‘nationalformularyforlaboratorytesting’recommendedbyLordCarter.Itsassociatedguidanceontestusewillfacilitatethedevelopmentofexpertdecisionsupportsystemsthatshouldmaketheuseoflaboratorytestsmoreefficient.Theseworkstreamsdeservecontinuingcentralsupporttoachievelaboratoryoutputsthatarecomparableforcommissioners.

Inaddition,sothattherecanbeassurancethatthequalityofcaregivenbyeachlaboratoryismaintainedduringtheperiodofNHSreorganisationandafterwards,theCollegewillassistwherepossibleintheproductionofqualityindicatorsforpathology.

TheCollegehasalreadymadeavailableanexampleofaservicespecificationforcommissionersofpathologyservicestoinformthecreationofregionalandlocalspecifications.5

New developments and molecular testing

“Newinvestigationsshouldbeevaluatedonthebasisnotonlyoftheiranalyticalvalidityandclinicalvalidity,butalsoontheirclinicalutility.Clinicalutilityincludesacost-benefitanalysis,wherecostsandbenefitsshouldbeevaluatedbytheimpactofthenewtestonthewholepatientpathway,notmerelytheimpactwithinthelaboratory.”1

TheRoyalCollegeofPathologistsisdevelopingadviceonastratifiedapproachtothedevelopmentofmoleculartesting,crucialforqualityinhighlyspecialiseddiagnosticservices.6

Thereisastrongpushfromtheirmanufacturersfortheuseofmoremoleculartests,yetmanyarenotnecessaryorareunproven.Giventhisconflictofinterest,andthatknowledgeaboutthesetestsamongstpathologistsisvariable,purchasingofthesetestsshouldbepartofspecialistcommissioningwithaclearevidencebaseforimplementation.

Thepotentialofmolecularteststofocusclinicalresourcesandimprovebothqualityandefficiencyofhealthcareinthefutureisanimportantreasonforprotectingtheskilledworkforceandacademicresourcesofpathology.

Intelligent commissioning

“Aprovidershouldnotbeallowedonlytoofferarestrictedrangeofcommonlyused

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tests,withtheexpectationthatadifferentcontractwithadifferentproviderwillcovermoreesotericneeds.LordCarterrecognisedthatthe‘cherry-picking’ofhigh-volumetestscoulddestabilisetheprovidersofesoterictests,totheultimatedetrimentofpatients.”1

Asaprofession,pathologists–includingtheRoyalCollege–arekeentoworkwithGPcolleaguesintherunuptoGP-ledcommissioning.Partnershipworkingwillbeimportantifthetransitionistobesmooth,qualityofcareprotected,andimprovementsintheirknowledgeofthespecialtymade.Pathwaymappingwillbeacriticaltoolinservicedevelopmentandpathologistswilltakeanactiveroleinthis.

CertainspecialistpathologyservicesintheUKareprovidedbyasmallnumberoflaboratoriesandspecialistsandhavepoororunder-prioritisedsuccessionplanning.IftheseservicesaretoremainintheUK,thereneedstobemorelocalsupportforthesesmallerservices.

Toensureoptimalpatientcare,itisessentialthatcontractsforlaboratoryservicesallowlaboratorystafftoinitiate‘reflextesting’,whereanunexpectedlaboratoryresultimmediatelyjustifiesfurthertestingofanyresidualsample.Toinsistongoingbacktotheclinicianandthepatientbeforeundertakingthefurtherinvestigationcancausedelay,confusionandharm.Theethicsofreflextestingmustalwaysbeconsidered,butitisusuallyjustifiedbytheobservationthatpatientsnormallyrequestinvestigationoftheirillness,notlimitingconsenttomeasurementofaspecificanalyte.

InarecentarticleinThe Times,ChrisHam,theCEOoftheKing’sFund,raisedconcernsabouttheeffectsofthecommissioningplanslaidoutinthecoalitiongovernment’swhite

paper:“Ministersshouldrecognisetheneedtosupportcollaborationinsomeareaswhilepromotingcompetitioninothers.Improvingresultsforpatientswithcancerorstrokevictimsrequiresformingnetworksofhospitalswillingtoconcentrateservicesinfewercentres.Rulesmakingitdifficultforspecialistnetworkstodevelopbecausetheyareanti-competitivewouldworkagainsttheGovernment’saims.”7

Information technology and disintermediation

“TheoperationalsuccessofrationalisationofpathologyserviceswillbeheavilydependentonefficientandreliableIThomogeneityandconnectivitywithinanygivennetwork.Completeuniformityofreferencerangesandunitsofmeasurementandreliablemethodsforidentifyingpatients(ideallyNHSnumber)areobviousprerequisites.”1

Developmentsininformationtechnologycontinuetoallowimprovementsinthequalityandefficiencyofcare.

Thereareofcourseimplementationcosts,butelectronicrequestingandreportingsystemscandecreasetranscriptionerrorsandenablesampletracking.Decisionsupportsystemsembeddedintheorderingsystemcanbelinkedtocarepathwaysandcanintroduce‘rules’onfrequencyoftesting.Asnotedabove,thishasthepotentialtogenerateconsiderablecashsavingsaswellasimprovementsincare.UsingITforreportingacrosslaboratoryandclinicalnetworksandspecialistlaboratorieswillspeedreceiptofresultsandgeneratecashsavings.

SuchdevelopmentsrequiretheconsistentuseoftheNHSnumberastheuniquepatientidentifierandthecompletionanduptakeoftheNationalLaboratoryMedicineCatalogue.

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Clinicalpathologyprofessionalscanusepathologytestresultstotriggerappropriateactions,forexampledetectionofacutekidneyinjuryandearlydetectionofliverdisease.

Standardisationofpathologydataenablesitsusewithinclinicalnetworks,withindiseaseregistriesandforsecondaryuses,includingresearch.ThePathologyFuturesGrouphasidentifiedmanyareaswherethecarepathwaycouldbeclarifiedandspeededupifthelaboratorywasencouragedtointeractdirectlywiththepatient.8

TheRoyalCollegeofPathologistsandtheRoyalCollegeofGPshaveissuedstatementsonthedeliveryoflaboratoryresultsdirectlytopatients.9Thisisnotappropriateinallcircumstances,butitisanticipatedthatsuch‘disintermediation’wouldfree-upthetimeofotherclinicians,particularlyGPs,enablepatientempowermentintheirlong-termconditionsandhencegainhigherpatientsatisfaction.

Leicester’smodelofdirectpatientcontactforthyroidreplacementtherapyisagoodexampleofthisworkinginpractice.Directreferralbyhistopathologiststocolposcopyclinicsbasedoncervicalcytologyfindings(directreferral)isanother.

Oneregularcomplaintfromtraineesonrotationbetweendifferenthospitals,evenwithinthesameregion,istheinefficientwasteoftheirtimecomingtogripswiththeheterogeneityoftheITsystemswithoutwhichtheycannotworkandlearn.

Clinical leadership in pathology

“Reorganisationandconsolidationofmedicallaboratoryservicescanofferconsiderablebenefits,butthecomplexityof

thetaskmustnotbeunderestimated.Itisthereforeessentialthatpathologists,whobytheirworkunderstandsuchcomplexityandhavethebestinterestsofthepatientsatheart,provideleadershipinthisproject.”1

TheRoyalCollegeofPathologistshasbeenprovidingguidanceandsettingstandardsfortheprofessionsince1962andanationalpathologyclinicaladviserwasappointedbytheDepartmentofHealthin2004.

ThedesireforimprovedclinicalleadershipinpathologywasstatedbyLordCarterofColesinhisfirstReport of the review of NHS pathology services in England,publishedin200610andreiteratedmorerecentlyinhissecondreport,publishedlatein2008.11Alsoin2008thethenHealthMinister,LordDarzi,putclinicalleadershipatthecentreofhisNextStageReview.12

Inadditiontodriverswhichareexternaltopathology,intheprofessionthereisanappetiteforincreasedvisibility.ThedevelopmentofNationalPathologyWeekandtheCollege’spublicengagementprogrammereflecttheperceptionwithintheCollegethattheprofileofpathologyneedstobeimproved.

AsmallleadershipgrouphasbeensetupintheCollege,ledbyitsvice-presidentsDanielleFreedmanandTimWreghitt,andincludingIanFrayling,RachaelLiebmannandRichardHerriot.

InNovember2009,anemailwascirculatedtoallthoseaffiliatedtotheRoyalCollegeofPathologistsintheUKaskingthemtoparticipateinanelectronicsurvey.Almost600responseswerereceived,ofwhichalmost100percentfeltthatclinicalleadershipcan‘makeorbreakpathologyservices’.

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Again,almostallrespondentsfeltthattheCollegehasaroleinthedevelopmentofclinicalleadership,buthalftherespondentsfeltthattheCollegedidnotcurrentlygiveadequatesupporttoclinicalleadership.

TherewasaverystrongfeelingthattheCollegehasaroleindevelopingandpromulgatingtheconceptofleadershipinitsfellows,bothcurrentandfuture.ThisissomethingthattheCollege,withtheguidanceoftheleadershipgroup,iscommittedtoproviding.13

ApilotprogrammeofpathologyleadershipdevelopmentsetupbytheDepartmentofHealthin2009wasinitiallytakenupbytwoSHAs–WestMidlandsandSouthEastCoast.Theprogrammerecruitedscientists,managersandmedicsinpathologyandinvolvedaseriesofintensecoachingsessionswitheducationinboththeoryandpracticalstrategiesforleadership.Feedbackfromtheparticipantswasuniversallypositive,andthepilotculminatedinpresentationsinJuly2010atpresentationandawardsceremoniesheldinKentandatWarwicktomarktheachievementsofallparticipants.TheprogrammeisbeingrolledouttoafurtherthreeSHAs,withdiscussionson-goingaboutleadershipdevelopmentcoveragemorewidely.

“Thereconfigurationofpathologyservicesisachallenge;buteverychallengeisaleadershipopportunity.”1

Who should do what?

Theareasdiscussedatthismeetingwerewide-ranging,andimplementingthechangesdiscussedwilldemandtheinvolvementofmanygroups.Thiscomplexitycouldleadtoparalysisiftheneedforsharedactionisnot

recognised.Wethereforesuggestthefollowinganalysis.

Group A. Activity largely within the practice of pathology

Workthatpathologistscan(andshould)dowithinthecompassofourownspecialtiesorworkplace.Thismaybeoflittleinteresttoanyoneelsesavetotheextentthatitimprovesthequality,safetyandcost-effectivenessoftheservice.Activitiesinclude:

productivity•

disintermediationandharmonisationoftests•

workforcere-profiling•

informationtechnology(someaspects).•

Group B. Activity at the interface with clinical care

Someofthiscanbeachievedwithinpathologydepartments,butmuchwillrequiremajorchangesinclinicalbehaviour,withoutwhichtherearefewpracticalbenefits;soagreementswithstaffoutsidepathologydepartmentsareessential.Behaviourmodificationrequiresresources.Activitiesinclude:

demandmanagementinprimarycare•

demandmanagementinsecondarycare•

useofresults•

informationtechnology(someaspects)•

opendata•

markertests•

POCT.•

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Group C. Activity that integrates into the clinical QIPP pathways

Amorecomplexareatouchedoninthediscussionbutnotexplicitinthediscussion.Thisincludestheuseofpathology(testsandexpertise)toreducehospitaladmissions,expediteearlydischarge(cuttinglengthofstay)andfacilitatethepatientpathwayinthemanagementoflong-termconditionsandintheelectivecarepathway(admissions,lengthofstayandoutpatientappointmentscanallbereducedwithashiftinthelocationofcaretowardsthecommunity).

Group D. Activity that requires political/commissioning input from pathologists locally and from the Royal College nationally

Merelyaddressingtheshort-termqualityandproductivitychallengesofthedownturnwillfailboththeNHSandthepublicinthelongtermunlessattentionispaidtofuture-proofingtheservice.Thiscanbechallengedbyshort-termcommercialinterests.AgoodexampleistheinternationalcommissioningofreportingofcervicalsmearsintheRepublicofIreland,whichalmostcausedirreversiblede-skillingoftheentirecountry.

Actionsincludeensuringthatthecommissioningprocessincludesconsiderationof(andallocationoffundingtosupport):

specialist(regionalornational)pathology,•includingmoleculartesting

teachingandtraining(ofclinicalaswellas•labstaff)

researchanddevelopment.•

Contributors

DrNeilAnderson,CDofCoventryandWarwick•PathologyNetwork–ClinicalBiochemistry

DrIanBarnes,NationalClinicalDirectorfor•Pathology,DepartmentofHealth–ClinicalBiochemistry

DrJulianBarth,President,ACB–Clinical•Biochemistry

DrBillBartlett,NinewellsHospital,Dundee–•ClinicalBiochemistry

DrGiffordBatstone,NationalClinicalLead•forPathology,OCCO,NHSCfH–ClinicalBiochemistry

DrBernieCroal,AberdeenUniversityMedical•School–ClinicalBiochemistry

DrDanielleFreedman,Luton&Dunstable•Hospital,RCPathExec–ClinicalBiochemistry

DrIanFry,FrimleyParkHospital,Surrey–•ClinicalBiochemistry

MrPhillipHurley,LaboratoryManager,•BiochemistryandImmunology/TrustPOCTlead,HeartofEnglandNHSFoundationTrust

SamanthaJayaram,RCPathPressand•CommunicationsManager

DrSimonKnowles,YeovilDistrictHospital–•Histopathology/Cytopathology

DrRachaelLiebmann,Kent,RCPathExecand•ClinicalDirector,KentandMedwayPathologyNetwork–Histopathology

DrSuzyLishman,Peterborough,RCPathExec–•Histopathology/Cytopathology

DrAngusMcGregor,LeicesterRoyalInfirmary–•Histopathology

MrJeffSeneviratne,GreaterManchester•PathologyNetwork–ClinicalBiochemistry

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DrCharlesSinger,RoyalUnitedHospital,•Bath;RCPathExec–Haematology

DrSusanStewart,Cambridge,RCPathCouncil•–Histopathology/Cytopathology

ProfessorMikeWells,Sheffield,RCPathExec•–Histopathology

DrTimWreghitt,Cambridge,RCPathExec–•Virology

References

Reconfiguration of NHS pathology services: 1.a statement from the Royal College of Pathologists.www.rcpath.org/resources/pdf/reconfiguration_of_nhs_pathology_services.pdf

‘Thefutureofpathologyservices’.2. Health Service Journal,16Sept2010.

Histopathology of limited or no clinical 3.value.RCPathpublication.www.rcpath.org/resources/pdf/HOLNCV-2ndEdition.pdf

www.journals.elsevierhealth.com/4.periodicals/ycdip/article/S0968-6053(04)00082-1/abstract

RCPathsupportedservicespecification.5.www.pathology.plus.com/docs/PathServiceSpecKM.pdf

The future provision of molecular diagnostic 6.services for acquired disease in the UK.www.rcpath.org/resources/pdf/pubs_moleculardiagnosticservices_oct10.pdf

www.thetimes.co.uk/tto/opinion/7.columnists/article2756292.ece

www.laboratorymedicine.nhs.uk/8.labmedicine/Portals/0/PathologyFutures/Path_Futures_Vision_FINAL.pdf

StatementoftheRoyalCollegeof9.Pathologistsonthedeliveryofmedicallaboratorytestresultsdirecttopatients.www.rcpath.org/resources/pdf/rcpath_results_direct_statement_v12.pdf

LordCarterofColesFirstReport.10.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4137607.pdf

LordCarterofColesSecondReport.11.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091984.pdf

LordDarzi’sNextStageReview.12.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf

‘Clinicalleadershipinpathology’,13. RCPath Bulletin,Oct2010.www.rcpath.org/resources/pdf/Oct2010bulletinclinicalleadershipinpathology.pdf

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OrthopaedicsThe following recommendations were produced by the British Orthopaedic Association and the British Orthopaedic Directors Society to highlight where resources could be released in NHS orthopaedics services, while maintaining or enhancing quality.

Discharge planning and length of stay

There is good practice in discharge planning amongst the best units, but significant variation – both between orthopaedic surgeons and the quality of local social services.

Enhanced recovery is being done in some form across the country, but could be done better.

Improvements could be made by having more active, consultant-level participation in multi-disciplinary musculoskeletal assessment clinics, alongside the other relevant professions (for example, social care and physiotherapy). Where problems are identified, they should be referred to the appropriate specialty (for example, geriatrics, anaesthetics or general practice) before they can go onto the surgical waiting list

A further development that would help would be if patients were not referred by their GP for consideration of surgery until they had undergone a fitness check in primary care. This could identify in advance those factors (particularly chronic diseases) that are likely to delay admission or discharge.

Improvements in this area could have a significant impact on costs, it was thought.

Pre-operative assessment

All patients coming for elective surgery should have a robust pre-operative assessment with input at an appropriate (i.e. consultant) level.

An unintended consequence of this that would

Themes

Discharge planning and length of stay•

Trauma •

Unnecessary referral•

Procedures of questionable value•

In-theatre efficiency•

Implants•

Cancellations•

System-wide issues•

BritishOrthopaedicAssociation

Context

Orthopaedics are behind most other specialties in meeting the 18 weeks target.

However, it began from a much lower starting point. Pathway redesign work so far has resulted in a 300 per cent improvement on June 2007.

Improvements beyond this point will be very hard, particularly with population changes and orthopaedics having the highest number of surgical admissions.

Current practice leads to a lot of short-term, expensive treatment being done just before the 18 week deadline, evening and weekend work etc. Such eleventh hour interventions are not sustainable, particularly with rising demand.

So a priority for the specialty is to do more surgery, more quickly, but in the present context it also needs to save money too.

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needtobeinvestigatedfirstiswhetherthesechangescouldgenerategreaterdemandforhighdependencybeds(forpatientswithmoresignificantco-morbidities).Thiscouldresultinmoreon-the-daycancellationsifthosebedsareunavailable.

Trauma

Traumasurgeryfororthopaedicsislikelytobeamorefertilegroundforcostsavingsthanelective.

Itishardtomanage,historicallyneglectedandunderfunded.Becauseoftheunpredictabilityoftraumaitcanbedifficulttomatchcapacitytodemand.

Traumaneedstobeallowedtobegivengreaterprioritybyorthopaedicsurgeonsandtheorganisationstheyarepartof.

Ingeneral,surgeons’jobplanningshouldnotmeanthattheydoelectivesurgerywhilsttheyareoncallfortraumaatthattime.

Itshouldbebothasurgicalandmanagerialaimtogetallpatients,includingthosewithfracturedneckoffemur,operatedonwithin48hours.Everyextrahourinbedraisescostandrisksofcomplications,whichleadtosignificantunnecessarycosts.

Unnecessary referral

KnowledgeoforthopaedicsamongstGPsisinadequategiventheproportionoftheirpatientsexhibitingorthopaedicproblems.Onesolutiontothiscouldbelocalorthopaedicsurgeonsmeetingwiththeirprimarycarecolleaguesandcommissionerstosetlocalguidelinesforwhattoreferandwhen,andwhattodobeforereferringetc.

MapofMedicinecouldbeusedtosupportthis,ashasbeendoneinDevonoverthelast18months.WorkisalreadyongoingtodevelopacompetencypackageonthemostcommonaspectsoforthopaedicstodevelopGPs’competencies.

Thereissignificantpotentialforsavingsthroughimprovedmusculoskeletal(MSK)services.Morerobustandefficientpathwayswouldensuretheappropriateuseofsurgerywhereindicatedandcouldsavetheuseofunnecessaryresources.

Onceapatienthasbeenreferredforanoperation,thereisadisincentiveforrefusingthisifitwouldbeofquestionablevaluetothem–ittakeshalfanhourtoexplaintothatpatientwhytheoperationwillnotgoahead,versusfiveminutestosayyes.Therefore,inprinciplethesurgicalteamwhoputthepatientonthewaitinglistshouldbetheteamwhoperformtheoperation.

‘ChooseandBook’createsinefficiencywhenprimarycarereferstothewrongspecialist.Surgeonswithinaunitarenotallowedtorefertoeachother,meaningtheymustsendthepatientbacktotheGP,whowillhavetofindanotherslotwiththecorrectsurgeon.Allowingsurgeonstorefertoeachother,aswellasseniorinputatthefrontendofreferral(andalsogreatercontinuityofcare)wouldallhelpwiththisproblem.

Procedures of limited benefit

Thereare,foranumberofreasons,unnecessarysurgicalinterventions,oratleastinterventionsoflimitedbenefit,thatarecurrentlydone.

Triageisoneareathatgeneratesunnecessarycosts(forexample,scans)whenconductedbyinadequatelytrainedandsupportedstaff.

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MRIuseisasignificantexampleofoveruse:

Alocalinvestigationbyoneofthegroup•showed80percentofusewasunnecessaryandjustcreatedunnecessaryonwardreferral.

AccesstoMRIcouldberestrictedto•consultant-level.Atpresentitisgrosslyoverusedthroughbeingabletoberequestedbymanydifferentpractitioners(forexample,physiotherapists)andatlowlevelsofseniority.

Alternatively,accesstoMRIcouldberestricted•sothatthoserequestingit:

havebeenproperlytrainedtointerpret–theresults

areabletospeaktothepersonwhowrites–thereport(whoisoftenbasedoverseasatpresent).

OveruseofMRIisalsoencouragedbystrategichealthauthoritiespurchasinggenerousbulkcontractsfromcommercialcompanies.Thisincentivisesoverusetouseupthefullquota.

In-theatre efficiency

Therearesignificantgainsstilltobemadeintheefficiencywithwhichtheatresarerun,althoughtheextenttowhichorthopaedicsonitsowncanmakeacontributiontothisislimited.

Theanaesthetist,surgeonandtheirteamsneedtobeavailableandpresentwellinadvanceofthescheduledliststart-timetoensurefulluseoftheavailableresources.

Considerationcouldbegiventoall-daytheatrelists,whichwouldhelpeasethelog-jamthatcurrentlybuildsuptowardstheendofeach

day.Alternatively,morefocuscouldbeplacedonusingtheexistingfivedaysmoreeffectivelybeforeallowingtheatretimetoamorphouslyexpand.

Implants

Thecurrentsystem,whereeachindividualhospitalpurchasesitsownimplants,issub-optimal.

Thereareoftenover100variantsforaparticularimplant,forexamplehipreplacements,whenin90percentofcasessurgeonscoulduseonlythosefewrecommendedinNICEguidelines.

Thefollowingcaveatsshouldbeaddedtothis:

roomforinnovationmustbeallowed•

wherethereisaparticularreasonwhya•surgeonwishestodosomethingdifferently,theyshoulddiscussitwithandseektheapprovaloftheirpeers.

Useofimplantsintraumaneedstoberationalisedinasimilarwaytothatofjoints,i.e.aregistry.

TheremaybescopeforincreaseduseofplasterofParisratherthanimplantsasthecostislowbutqualityofcarecanbejustashigh.However,thiswouldrequirerediscoveryofsomeoftheskillsneeded.

Cancellations

Someofthecurrentbestpracticeinmanagingcancellationsneedstobereplicatedmorewidely.Forexample,meetingwiththe

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wholeunitteamonaweeklybasistolookatcancellationsthatoccurredandassesshowtheymighthavebeenavoided.

Oneofthemajorcausesofcancellationsisalackofcapacity.

System-wide issues

Consultantsarecurrentlypaidextraforextrawork(forexample,clinicsandoperatinglists)andarethereforeincentivisedtotakelesstimedoingbasicpatientworkandwardrounds.Thispushesthesetasksontoseniorhouseofficers(whohavelesscontinuityofcarewiththepatient)andresultsintestsbeingrepeatedwithnoonereallymanagingthepatient’scare.

Ontheissueoftheatreefficiency,worktobringanaesthetistsmorecloselyintoateamworking

culturewouldbeeffective.

Thethresholdsthatjuniordoctorsmustreachbeforebeingpromotedaregettinglower,meaningthecompetenciesofcareergradeorthopaedicsurgeonsarelowerthantheyusedtobeandahigherproportionoftheserviceisbeingdeliveredbynon-consultants.Apropercareerpathwayforpre-consultant-leveldoctorsisneeded.

Medicalschooltraininginorthopaedics/trauma,oftenaslittleastwoweeks,isinsufficientgiventhepervasivenessoftheseconditionsatalllevelsoftheNHS.

TheEuropeanWorkingTimeDirectiveneedstoberecognisedasacauseofmuchunnecessarycost.Agencybillshaverisensignificantlyasaresult.Manytrustsarefindingitdifficulttoemploystafftofilltheirrotas.


Mr Mike Bell, Immediate Past President, BOA (Sheffield)

Mr Steve Bollen (Bradford)

Mr Dave Clark (Derby)

Mr Tony Hui, Immediate Past President, BODS (Middlesborough)

Mr Peter Kay, President, BOA (Wrightington)

Mr Mike Kimmons, Chief Executive Officer, BOA

Mr John Marshall (Devon)

Miss Clare Marx, Past President 2008/09, BOA (Ipswich)

Mr Sudhir Rao (South London)

Mr Jeremy Ridge (Dewsbury, Mid Yorkshire)

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NeonatologyThe following recommendations emerged from the British Association of Perinatal Medicine’s group regarding areas that could be explored in terms of improved efficiency in their specialty.

Dischargeplanning:

thereisaneedforqualitydischargeplanning•tobecomestandardpractice.Thisdoesnotimplysendingpeoplehomeearliertomeetatargetorreducecosts,butworkingwithparentsfromthepointofadmissiontoplandischarge

mythsandoutdatedrulesaroundonly•dischargingbabiesaboveacertainweightorcertainagestillperpetuateinneonatalunitsaroundthecountry

improvingthedischargeprocesscouldleadto•fasterreleaseandfewerbeddays.

Tests–thereisscopeforstandardisingtheuseofcertaininvestigationssuchasMRI.

Follow-upprocedures–atpresentthereisgreatvariationinthecriteriaforfollow-upafteranadmissiontotheneonatalunit.

Feedingpractices:

anationalapproachtototalparenteral•nutrition(TPN)shouldremovevariationinpractice,improvequalityofcareandreducerisks

thereisgreatvariationintheintroduction•andmanagementofeneteralfeeding.ImprovedguidanceagreedamongstnetworkshasthepotentialtoreducetheneedforTPN

thereisagreatdealofvariationin•breastfeedingsupport.Greateravailabilityofmothers’breastmilkcouldsimilarlyreducetheneedforTPN.

Themes

Reduce non-rational variation in practice•

Stronger networks•


‘24 weeks and below’ position•

Use of SHOs/junior doctors•

Systemic issues•

Reduce non-rational variation in practice

Currently,thereiswidespreadvariationinpracticethatdrivesincreasedcostwithoutevidentialsupport.Thisaffectsnotjustthetypesoftestsdone,butbasicpracticearoundwhentoadmitandwhentodischarge.

Theareastoaddressarelistedbelow.

Inappropriateadmissions,suchas:

highratesofbabiesadmittedtoneonatal•unitswithoutrequiringanymedicalintervention–ratesarereportedtorangebetween9percentand37percentofnormalbirths.Thisvariationdoesnotseemtobelinkedtoanyparticularfactorandprobablyrepresentsestablishedpractice

routineadmissionofbabieswhosemothers•havediabetes

inappropriateuseofspecialcare.•

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Drugs:

harmonisepracticeregardingthedurationof•antibioticsuseandthetimeneededtogetnegativecultures(inordertoallowantibioticstostop)

clearerguidanceregardingtheuseof•Palivizumab

FetalFibronectinisrecommendedin•numerousdocuments,yetisnotuniversallyused.Ithasthepotentialtoreducethenumberofwomentransferredunnecessarily(becauseofaperceivedriskofpre-termdelivery)

NICEguidanceonantenatalsteroiduse•amongstnear-termbabiesisrequired.

Otheraspectsofvariablepractice:

transfusion–everynetworkshouldagreea•protocolfortheuseofbloodproducts

infectioncontrolproceduresarestillsub-•standardinmanyunits,especiallyinrelationtothecareoflonglines

equipment–single-useitemsareabigarea•ofwastage,particularlyforhighvolumeprocedures

training–newbornlifesupport(NLS)or•equivalenttrainingcostscouldbereducedbyusingadifferentsupplier.Thereisalsopotentialforthecourseitselftobesimplifiedformanystaff.

Howmuchofthisvariationshouldbereducedwasdiscussed.Theimportanceofbenchmarkingpracticeandusingthesedatatochallengeoutlierswashighlighted.Cliniciansvaryingfromthenormshouldbemadeawarethatitwastheirprerogativetoexplainwhytheydifferedfromtheirpeers.However,itwasnotfelttobeappropriatethatindividualscould

dowhattheylikeduntilitwasproventobeineffective.

Itwasnotfeltthatpatientswouldbeconcernedaboutthedegreeofclinicianautonomythatcouldbelostthroughthesemeasures.Itwasmoreconcerningtothemthattheycouldbegivenacompletelydifferentcourseoftreatmentdependingonwhichunittheywenttoorwhichdoctortheysaw.

Stronger networks

Strongernetworksinneonatologywerefelttohavegreatpotentialforthebetteruseofresources.Examplesaregiveninsomeoftherecommendationstoreducevariation(seeabove).

StrongernetworkdeliveryofneonatologywassupportedinthemostrecentNationalAuditOfficereportonneonatology.

Inadditiontotheexamplesabove,theycouldcreatemuchmoreefficientmovementofpatients,betterbeduse,fasterreleaseand,perhapseventually,fewersitesinwhichneonatologywasdelivered(althoughitwasrecognisedthatthislastpointreliesonseveralotherfactors).

Demand management

Thereisalimitedextenttowhichtheremitofneonatologyallowsitspractitionerstohaveanimpactonthedemandthatexistsfortheirservices.

Onemajorareawheretheycanmakeadifferenceisunnecessaryreferral(seevariationsectionabove–Fibronectin).

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Ofpatientswhodoneedneonatalcare,itwassuggestedthattakingagreaterinterestinthelinksbetweenat-risk(forexample,drug-dependent)mothersafterthebirthofachildandfamilyplanningservicescouldreducefuturepre-term/unsafebirths(andhencedemand).Whilethebabyistechnicallythepatient,andhencetheneonatologist’sprimaryconcern,neonatalservicescommonlyofferotherresourcesandinformationthattheyfeeltheparentneeds,andhencethegroupfeltthatbetterlinkswithfamilyplanningwouldnotrepresentanyconflict.Thiscouldbebuiltintothedischargeprocess.

‘24 weeks and below’ position

Itisimportanttorecognisethedebateonwhethertreatmentshouldberefusedtoveryimmaturebabiessuchasthoseunder24weeksofgestation.However,thissituationhasbeenclearlysetoutintheBritishAssociationofPerinatalMedicine’sandtheNuffieldTrust’spositionstatementsonthistopic.

Itwasthoughttobeworthre-emphasisingthatabroadclinicalconsensusdoesexist,albeititisnotwidelyunderstoodbythepublic.

Under24weeks’carewasnotthoughttobeasignificantcostissueforthespecialtyasthenumberofpatientsissmall.Notmentioningthisissueaspartofthediscussionswouldinviteittobehighlightedasanomission.Itisanimportantissue,butnotanimportantcostissue.

Use of SHOs/junior doctors

ThecurrentmodelofSHOuseissub-optimal.ABritishAssociationofPerinatalMedicinestatementonstaffingmodelsispartofthe

BritishAssociationofPerinatalMedicine2010standardsdocument.

Manybasiccompetenciesamongjuniordoctorsareunsatisfactory.Theyshouldnotbeallowedtoprogressintheirtrainingiftheycannotdemonstrateacertainlevelofcapability.Thiswouldhaveanimpactonpatientsafetyandwaste.

Other system-wide issues

Themovetomoretransitionalcareandbetterhomecarepackagesisbeingblockedbysometrustsastheproperincentivestomovecareoutofhospitalsdonotexist.

Thereshouldbeanationalprocesstojudgewhethercertaininterventionsaretrulyeffective.Whereevidencedoesnotexist,‘borderlineinterventions’shouldbeintroducedinawaythatallowsproperassessmentbeforewidespreaddissemination.Thiswouldsupportneonatologytoimplementsomeoftheaboverecommendationsonvariationbyprovidingagreaterevidencebaseonlow-valueinterventions.

ThereisariskthatifPCTscutthequantityofIVFavailable,morepeoplewillgoabroadfortreatment,wherethestandardnumberofeggsimplantedishigher.ThiscouldleadtomoremultiplebirthsbackintheUK,requiringmoreexpensiveneonatalcare.

Publiceducationoftherisksofhavingchildrenprematurelyshouldbebetter.Ifnothingisdonetocombatrisingexpectations,thedemandforneonatologywillcontinuetoincrease.

Therearefewsystemicleverstodrive

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Dr Eleri Adams, Oxford Radcliffe Hospitals, consultant neonatologist

Dr Pam Cairns, University Hospital Bristol, consultant neonatologist

Mr Andy Cole, Chief Executive of BLISS

Prof David Field, President of BAPM

Dr Simon Struthers, Winchester and Eastleigh, consultant paediatrician

Dr Merran Thomson, Queen Charlottes and Imperial, consultant neonatologist

Dr Miles Wagstaff, Gloucestershire, consultant paediatrician

standardisation.PCTsarenotabletotakethisroleastheylacksufficientdetailedknowledgeofthespecialty.

TheNHSPassport,ifitcomesabout,willbeasignificantassetinmakingbetteruseof

neonatalstaffbymakingthemfreertomovearoundanetwork.

Thehighlydistributedwaythatneonatologyiscurrentlyorganisedcouldberationalised,althoughthiswouldofcoursereducechoice.

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DermatologyThe following recommendations were produced by the British Association of Dermatologists to highlight where resources could be released in NHS dermatology services, while maintaining or enhancing quality.

Patientsshouldseetherightperson,intherightplace,firsttime,toobtainadefinitivediagnosisandensurethattheyaresubsequentlyseenbythemostcost-effectivememberoftheteaminprimaryorsecondarycare,appropriatetotheirdiagnosis.Thisismostefficientlyachievedbyconsultanttriageofreferralletters.Forthemostcommondiagnosesthiswillusuallymeanthepatientinitiallyseeingaconsultantdermatologistorbyaservicewhichhastimelyaccesstoaconsultantifneeded(i.e.anintegratedservice).

TosupportthetransitionfromPCTtoGPcommissioningtheBritishAssociationofDermatologists(BAD)willfacilitatetheproductionofevidence-basedguidelinesforcommissionersonmeasurementofqualityandoutcomeforskindiseaseinterventionsindicativeofahigh-qualityservice.Thiswillinvolveamulti-stakeholdergroupincludingpatients,nurses,GPs,dermatologistsandotherhealthcareprofessionalsinvolvedinthecareofskindisease.Aworkinggroupisalreadyintheprocessofdevelopingtheseminimumdataset(MDS)standardsnow,bothacrossdermatologyandbysub-specialty.

TheBADconsidersthattheseMDSstandardswillbeparticularlyusefulinanenvironmentof‘anywillingprovider’byhelpingcommissionersfindtherightbalancebetweencostandqualityofservicesandensuringpatientsgetthesamequalityofcarewhereverandbywhoeveritisprovided.

Demand management

1. Follow-up protocolsThereisagreatdealofvariationinfollow-uppractices,withmanypatientsattendingforfollow-upappointmentslongaftertheseaddvaluetothepatient.

Themes

Commissioning services for people with •skin conditions


Technology to triage referrals•

Reducing non-attenders•

Telephone consultations and non •face-to-face consultations

Generic substitution for prescribing•

Reducing unnecessary consultations•

Other varied initiatives•

Other system-wide issues.•

Commissioning services for people with skin conditions

EvidencetodatefromCareClosertoHome1andworld-classcommissioning2suggeststhatqualityservicesshouldbeintegrated.Toobtainbestuseofresources,allstakeholdergroups(commissioners,dermatologists,GPsandpatientgroups)shouldbeinvolvedinservicedesigntominimise‘blindalleys’andmaximiseefficientpathways.ConsultantsarethegreatestexpertresourceintheNHSandprocessesexcludingthemwillinevitablybeflawed,particularlyasundergraduateandGPregistrartrainingcontainminimaldermatology.

Forthe6percentofskindiseasewhichrequirespecialistassessment,evidencesuggeststhatthisismostefficientlyandeffectivelydeliveredbyamulti-disciplinaryteamledbyconsultantdermatologistswhocanbestprovideanaccuratediagnosisandbestmanageskincanceretccost-effectively.

36


Patientsshouldbefollowedupifthereisaclearindicationsuchas:structuredfollow-upforskincancer;thosepartofsharedcareprotocols;thoseimmunosuppressedpatientsbeingmonitoredforcancer;patientswithunstabledermatosesrequiringmodificationoftreatment;andthosewithunstablesolardamagethatrequireongoingtreatment.Forothers,ifnochangeinmanagementisrecommended,theyshouldbedischargedwithanappropriatemanagementplanwhichisagreedbythedoctorandpatient.Thisprocesswouldbefacilitatedforpatientswithchronicdiseasesiftheyfeltreassuredthattheywouldbereferredbackquicklyandeasilyiftheirsituationchanged,somethingwhichisbecomingmoredifficultinthecurrenteconomicclimate.

Patientsshouldhaverapidaccesstoappropriatediagnosticskillsasandwhenneeded.Ifthisprocesswaseasierthenitmayfacilitatethedelegationofmorefollow-uptomembersofthedermatologyteam.

Itshouldbeappreciated,however,thatfollow-upofthepatienttoseeifatreatmentplanhasworked,orreviewingasurgicalpatienttogainfeedbackonthesurgicaloutcome,arelearningeventsthatwillimprovefuturecare.Thelossoftheseencounters,whilstpossiblyreducingcostintheshortterm,reducesthelearningaspectsofpatientcare.

2. Procedures of low clinical priorityThecriteriaforlowpriorityproceduresarenotuniformlyappliedacrosstheNHS,andthereissomeunnecessaryvariationbetweensub-specialties.

IftheNHSwascleareraboutwhatitdoesanddoesnottreat,itcouldtakeadifferentapproachtotheseproceduresby,insteadofbanningthem,tellingpatientsthattheycanpaytohavethemdone.Thiswouldcreateasourceofrevenueforthehealthserviceand,sincemanycaseswouldinvolveminorsurgicalprocedures,wouldprovide

educationforjuniordoctorsandsomenurses.

Skintagsandseborrhoeickeratoseswouldbepossibleexamplesofareaswherethiscouldbedone.

3. Reducing unnecessary procedures in primary careProceduresof‘limitedclinicaleffectiveness’(POLCE)whicharenottobereferredtosecondarycare,unlessthereisdiagnosticuncertainty,shouldalsonotbetreatedinprimarycare.

Onequalitycontrolwhichcouldbeappliedlocally,wouldbecost-effectiveandthatdermatologistsshouldsupportisbiopsyofundiagnosedrashesandlesionsorremovaloflesions.Thisshouldnotbedoneunlessanduntilexpertopinionhasfirstbeengiven.

ThevalueofinsertingthedermatologistintothepatientpathwaybetweentheGPanddermatologysurgeryhasalsobeendemonstratedinsomeareas.Two-weekcancerclinicsreassureanddischarge80percentofpatientsandtherebysavesurgerycosts.Fortypercentofdermatologypatientsarereferredwith‘lesions’andmostofthesearereassuredanddischarged,therebysavingsurgerycosts.

Technology to triage referrals

1. Two-week cancer referral triageOnedermatologyunitreportedthattheyhadmanagedtomakesignificantproductivitygainsfromtheapplicationofteledermatologytotheirtriageprocess.Anotherunitusesapooloftrainednursesincommunityhospitalstomakeaninitialconsultationandtakepatienthistoriesanddigitalimagesoftheaffectedareasofskin.Thesearesenttothedermatologistelectronicallyfortriage.Thishasresultedinasignificant

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reductioninthenumberofnewpatientsthedermatologistneedstoseefacetofaceandhas,therefore,improveddepartmentalefficiencyandsomewaitingtimes.Patients,however,stillneedtotraveltothe‘communityhospital’anditisnotclearwhetherornottheresourcesneededforthelongernurseconsultationandphotography,combinedwiththeduplicateconsultationandtravelforthoseultimatelyseeingadoctor,resultsinasignificantsaving.

Suchmodelsarecurrentlystillcontroversialandthereisnoagreementintheprofessionaboutpatientsafety.Mostunitsdostillseeallsuchpatientssotriaged.

2. Triage of ‘rashes’Whenusedfor‘rashes’,teledermatologymayhelptriagebutonlyifhigh-qualityimagesarecombinedwithagoodhistory.Thismayallowupto20percentofreferralstoberedirectedtotheGP3butshouldonlybedoneaspartofanestablishedandintegratedserviceandshouldbecloselyauditedforcostandsafety.Thequalityandcost-effectivenessofoutsourcingeithertheimagingortriageshouldbeconsideredhighlyquestionable.

Reducing non-attenders

Consultationswherepatientsdonotattend(DNA)areaclearareaofwastedcapacity.

Simpleautomatedsystemsthattextand/oremailpatientswithremindersoftheirappointmentsignificantlyimprove,i.e.reduce,DNArates.InsomeareastheyresultedinDNArateshalving,withasavingofresourcewhichcanbereinvested.FewerDNAswillpermitanecessaryreductioninclinictemplates,whichcurrentlyallowfor‘noshows’.Theincreaseinthroughputwouldthenbemoderate.

Thecostofthesesystemsisnowsmallandthere

arevariousotherfunctionstheycanprovide,suchasusingthepatient’sfirstlanguageorremindingthemofparticulardocumentstheyneedtobringwiththemtoanappointment.

Telephone consultations and non- face-to-face consultations

Forpatientfollow-up,manyoftheface-to-faceconsultationsundertakenbydermatologistscouldbedoneasaconversationoverthetelephoneinstead,increasingproductivityandreducingpatienttransportcosts.Insomecases,suchaschronicdiseasemanagement,these‘follow-ups’couldbeconductedbyanurseinsteadofthedermatologist.

Someofthemostcommonconditionscouldbefollowedupthisway,suchaspatientswithchronicdiseases,thoseonsystemicdrugsetc.ThelatteristhesubjectofaQOF‘sharedcare’proposalwhichwouldreducesecondarycarefollow-upandimprovesafetyforthisgroupofpatientswhoareindangerofbeinglostduetonewpatienttargets.

CostsavingswouldaccruetothewiderNHSratherthanthetrustinwhichthedermatologistworks,sincethetarifffortelephoneconsultationsisconsiderablylessthanthatofaface-to-faceone.

Generic substitution for prescribing

Forcertaincommonsystemicdrugsthereisscopetoincreasetheuseofgenericsubstituteswithoutaffectingquality.ExamplesincludeIsotretinoinandciclosporin(aslongaspatientsreceivethesame‘brand’throughouttheirtreatmentcourseasbioavailabilitymaydifferbetweenproducts).

Electronicprescribinginsecondarycare(as

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existsinprimarycare)hasthepotentialtoreducecostsbyrestrictingprescriberstogenericagents,reducingtherisksofprescribingdrugswhichinteractandlimitingprescriptionstoagreedduration,allofwhichimprovesafetyandsavemoney.

ThelistofDermatologySpecials(www.bad.org.uk//site/1284/default.aspx)listsapprovedspecialformulationswhicharecommonlyusedbydermatologistsintheUK.Arrangementshavebeenmadeforthesetobeproducedcentrallyatlowcostandhighquality.Communitypharmacistsshouldbemandatedtopurchasetheseproductsfromthesecentresandnotfromsmallvolumeproducerswherecostsareinvariablyhigh.

Reducing unnecessary consultations

1. Modifying the pregnancy prevention planThepregnancypreventionplanstatesthatfemalepatientsoncertaincommondrugsprescribedbydermatologists(Isotretinoinandalitretinoin)mustbeontwoformsofcontraceptionandarerequiredtoattendthehospitalonceamonthforapregnancytest.

Theplanhasnotreducedtheincidenceofunplannedpregnancies,however,andtherationaleforitscontinuationisquestionable.

SharedcarewithGPswithSpecialInterestsinthecommunitymaybeeffectiveaslongastheyarecognisantofthesafetyissuesandareaccreditedbythedermatologistsunderwhosenamethedrugisprescribed,asdictatedbyMHRAguidance.

2. WigsDermatologistsarecurrentlytheonlyhealthpractitioners(otherthanoncologists)permittedtoprescribewigs.Thereisnoclinicaljustificationforthisrule,whichcreatesneedless

demandsondermatologyunitsandgeneratesunnecessarypatientvisitsfortheprescribingandrenewalofwigs.

TheabilitytoprescribewigsshouldbewidenedtoattheveryleasttoGPs.

Other varied initiatives

1. Management of cellulitisCellulitisisresponsibleforover£100milliononpatientcarenationallyintheNHS.Auditshowsapproximately30percentofpatientsdiagnosedwithcellulitisbyGPsandgeneralphysiciansinfacthaveotherdermatologicalcausesofredlegsanddonothavecellulitis.Consequently,admissionofthesepatientstohospitalforoneormoreweeksforintravenousantibioticsresultsinwastedbedstays,inappropriateadmission,inappropriateIVantibioticsresultinginCDifficileinfectionanddelayeddischarge.

Furthermore,muchcellulitisisduetounderlyingskindiseaseandthereforecellulitisisoftenrecurrentiftheskindiseaseremainsunrecognisedanduntreated.Lowerlimbcellulitiscan,ifcorrectlydiagnosedandmanaged,almostalwaysbetreatedathome.

Aninnovative,dermatology-ledlowerlimbcellulitisserviceintheNorfolkandNorwichUniversityhospitalhasoverthreeyearsalmosteliminatedinpatienttreatmentoflowerlimbcellulitisanderadicatedinappropriatetreatmentwithIVantibiotics.Patientsaremanagedathomewithhospitalvisitstomonitorclearanceandaimtopreventrecurrence.

2. Joint working with GPs to reduce demandManyGPscallorwriteletterstodermatologistsaskingforadvice.Thiscurrentlyisn’trecognisedasactivityandso

39


isn’tchargeable.Introducingatariffforthiswouldremoveperverseincentives,improvecommunicationbetweencliniciansand,studiesshow,reducereferral.

PaymentbyResultsrequirestheretobeapatientencounterforchargingtooccur.Forletter/emailortelephoneadvicetobechargeablethiswouldhavetochange,buttheBADwouldsupportthis.

3. Teaching and trainingTrainingandeducationshouldbeanintegralpartofanyproposedserviceifitistobeofhighqualityandsustainable.

GPeducationshouldbetargetedtothecommondermatoses.Whiletherearethousandsofskinconditionsthatdermatologistsneedtobeawareof,90percentofGPreferralsrelatetolessthan20conditions.Someofthesecasesdonotneedreferralorcanbemanagedinprimarycareoncethediagnosisisconfirmedandatreatmentplanagreed.Ifeachhealtheconomytargetedthediagnosisandmanagementofskinlesionsbyfundingface-to-facetuitionorviaexistingonlineeducationpackages,inappropriatedemandonspecialistresourcescouldbesignificantlyreduced.Dermatologistswouldsupportthis,butthechangesneededtomanageandresourcethisinitiativewouldrequireinvestment.

Other system-wide issues

Thecommissioningofanywillingproviderdoesnotresultincost-effectivehealthcare.Profitmakingproviderscancherrypickthoseaspectsofcarewhichareprofitablebutrarelytakeonthemorechallengingonesandexpensiveones.ThisleavesNHSorganisationswiththemoreexpensiveareas,forwhichtheystillrequiremostofthecostbasetheydidbefore.Commissioningshouldconsidertheentiredermatologyservicebasedonrobustneedsassessmentsandincludeallrelevantstakeholders.

Tariffmaysometimesencourageunnecessaryattendancesbyprovidinganincentivetogivingapatientafollow-upappointmentforadaycaseprocedureratherthanoperatingonaseeandtreatbasis.

References

www.bad.org.uk/Portals/_Bad/Official%201.Responses/Service%20models%20fig%20and%20evidence.pdf

NHSPrimaryCareContracting(2008).2.Providing care for patients with skin conditions: guidance and resources for commissioners.Leeds:NHSPrimaryCareContracting

SchofieldJK,GrindlayD,WilliamsHC.(2009).3.Skin conditions in the UK: a health care needs assessment.CentreforEvidenceBasedDermatology,UniversityofNottinghamUK

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Officers

Dr Tanya Bleiker, Editor, Derby

Dr David Eedy, Treasurer, N Ireland

Dr Mark Goodfield, past President, Leeds

Dr Catriona Irvine, Clinical VP, Canterbury

Dr Stephen Jones, President, Wirral

Dr Nick Levell, Hon Sec, Norwich

Dr Jane Sterling, Academic VP, Cambridge

Clinical Services Committee

Dr Robert Burd, Leicester

Dr Sheru George, Amersham

Dr Karen Gibbon, London

Other members

Dr Robert Chalmers, Manchester

Dr Ed Seaton, London

Dr Graham Sharpe, Liverpool

Additional comments received from

Dr D Mallett, Peterborough

Dr J Schofield, Lincoln and West Hertfordshire

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This joint publication brings together practical recommendations from focus groups with seven specialty medical societies and Royal Colleges, each of which were asked to suggest ways that clinicians in their own specialties can release NHS resources while maintaining or enhancing quality. Chapters include orthopaedics, neurosurgery,

dermatology, neonatology, pathology, vascular surgery and geriatrics. The recommendations will be of use to local commissioners and providers, clinical leaders, policy makers and anyone else seeking to address the most serious period of financial constraint in the history of the NHS.

Clinical responses to the downturn

The NHS Confederation29 Bressenden Place London SW1E 5DDTel 020 7074 3200 Fax 0844 774 4319Email [email protected]

Further copies or alternative formats can be requested from: Tel 0870 444 5841 Email [email protected] or visit www.nhsconfed.org/publications© The NHS Confederation 2010. The use of this publication is covered by the conditions of Creative Commons Attribution-Non-Commercial-No Derivative Works License: www.creativecommons.org/licenses/by-nc-nd/2.0/uk

You may copy or distribute this work, but you must give the author credit, you may not use it for commercial purposes, and you may not alter, transform or build upon this work.

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ISBN: 978-1-85947-186-9 Stock code: BOK60038 When you have finished with this leaflet please recycle it

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Clinical responses to the downturn