7 day services: applying the lessons to diagnostics -
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7 Day Services: Applying the Lessons to Diagnostics Erika Denton National Clinical Director for Imaging - presentation from seven day services in diagnostics event held on 4 March 2013 #7dayDiagnosticsTRANSCRIPT
7 Day Services:
Applying the Lessons to Diagnostics
Erika DentonNational Clinical Director for Imaging
March 4th 2013
7-day working
• What do we mean by 7 day working?
• Why change?
• How?
• Co-dependancies
• Challenges
Open 24 hours?
Providing NHS Services 7 days a week
“7 days a week” : what does it mean?
• Traditionally maternity & A&E only
• Primary care access and elective work
• Secondary care pathways
• System wide approach essential
Norfolk & Norwich University Hospital
NHS Foundation Trust
Why should we change?
• ↓ cost & make best
use of resources
• ↑ demand vs capacity
• ↓ length of pathways
• ↓ waiting
• Patients want us to
Projected Rate Of Population Growth By Age Last Birthday
0%
2%
4%
6%
8%
10%
12%
14%
16%
Year
Projected Population
Increase from 2004 %
Under 60 (% increase from 2004)
Over 60 (% increase from 2004)
Under 60 (% increase from 2004) 0.0% 0.5% 0.8% 0.8% 0.7% 0.9% 1.0% 1.3% 1.5%
Over 60 (% increase from 2004) 0.0% 1.4% 2.8% 5.6% 7.9% 9.8% 11.5% 13.1% 14.6%
2004 2005 2006 2007 2008 2009 2010 2011 2012
The vast majority of increase in population over the next 6 years is predicted to be in
the 60+ age bracket.
The vast majority of increase in population over the next 6 years is predicted to be in
the 60+ age bracket.
(Source: Government’s actuarial department).
Causes Of Death For Over 60s
IX Diseases of the circulatory
system
39%
II Neoplasms
26%
V Mental and behavioural
disorders
3%
XI Diseases of the digestive
system
4%
X Diseases of the respiratory
system
15%
VI Diseases of the nervous
system
3%
XVIII Symptoms, signs and
abnormal clinical and laboratory
findings, not elsewhere
classified
2%
All Others
8%
In 2004 the deaths 80% of the people over 60 who died could be attributed to three underlying causes
IX Diseases of the circulatory
system
39%
II Neoplasms
26%
V Mental and behavioural
disorders
3%
XI Diseases of the digestive
system
4%
X Diseases of the respiratory
system
15%
VI Diseases of the nervous
system
3%
XVIII Symptoms, signs and
abnormal clinical and laboratory
findings, not elsewhere
classified
2%
All Others
8%
In 2004 the deaths 80% of the people over 60 who died could be attributed to three underlying causes
Why did we have targets?
18/52, 2 week waits, 6 week waits etc etc
Aimed to take waiting times off the
agenda once and for all.
The Ideal in diagnostics?
A no wait system?
this will mean 7 day working….
‘In God we trust. All others must bring data’
W. Edwards Deming,
physicist and quality improvement pioneer
1 – Data refer to exams in hospital only.
2 – Data refer to exams outside hospital only.
1 – Data refer to exams in hospital only.
2 – Data refer to exams outside hospital only.
15 tests >6 week waiters April 2006 – Dec 2012
15 key tests
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
MRI >6 week waiters April 2006 - Dec 2012
MRI
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
AP
R 0
6JU
LY 0
6O
CT 0
6JA
N 0
7A
PR
07
JULY
07
OC
T 07
JAN
08
AP
R 0
8JU
LY 0
8O
CT 0
8JA
N 0
9A
PR
09
JULY
09
OC
T 09
JAN
10
AP
R 1
0JU
LY 1
0O
CT 1
0JA
N 1
1A
PR
11
JUL
11O
CT 1
1JA
N 1
2A
PR
12
JUL
12O
CT 1
2
CT >6 week waiters April 2006 – Dec 2012
CT
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
NOU >6 week waiters April 2006 – Dec 2012
NOU
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
AP
R 0
6JU
LY 0
6O
CT 0
6JA
N 0
7A
PR
07
JULY
07
OC
T 07
JAN
08
AP
R 0
8JU
LY 0
8O
CT 0
8JA
N 0
9A
PR
09
JULY
09
OC
T 09
JAN
10
AP
R 1
0JU
LY 1
0O
CT 1
0JA
N 1
1A
PR
11
JUL
11O
CT 1
1JA
N 1
2A
PR
12
JUL
12O
CT 1
2
Audiology >6 week waits Apr 2006 – Dec 2012
Audiology
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
Colonoscopy >6 week waiters April 2006 – Dec 2012
Colonoscopy
-
5,000
10,000
15,000
20,000
25,000
30,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
Flexi Sigmoidoscopy >6 week waiters April 2006 – Dec 2012
Flexi
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
Cystoscopy >6 week waiters April 2006 – Dec 2012
Cystoscopy
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
Gastroscopy >6 week waiters April 2006 – Dec 2012
Gastroscopy
-
5,000
10,000
15,000
20,000
25,000
30,000
APR 0
6JU
LY 0
6O
CT 0
6JA
N 0
7APR
07
JULY
07
OC
T 07
JAN
08
APR 0
8JU
LY 0
8O
CT 0
8JA
N 0
9APR
09
JULY
09
OC
T 09
JAN
10
APR 1
0JU
LY 1
0O
CT 1
0JA
N 1
1APR
11
JUL
11O
CT 1
1JA
N 1
2APR
12
JUL
12O
CT 1
2
KEY: Blue = Activity
Green = Number of patients waiting
MRI
MRI
-
50,000
100,000
150,000
200,000
250,000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
P 0
9D
EC
09
MA
R 1
0JU
NE
10
SE
PT 1
0D
EC
10
MA
R 1
1JU
N 1
1S
EP
11
DE
C 1
1M
AR
12
JUN
12
SE
P 1
2D
EC
12
KEY: Blue = Activity
Green = Number of patients waiting
CT
CT
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
NOU
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
JUN
E 0
6
SE
PT 0
6
DEC
06
MA
R 0
7
JUN
E 0
7
SE
P 0
7
DEC
07
MA
R 0
8
JUN
E 0
8
SE
P 0
8
DEC
08
MA
R 0
9
JUN
09
SE
PT 0
9
DEC
09
MA
R 1
0
JUN
10
SE
PT 1
0
DEC
10
MA
R 1
1
JUN
11
SE
P 1
1
DEC
11
MA
R 1
2
JUN
12
Waiting List Acti vi ty
US
KEY: Blue = Activity
Green = Number of patients waiting
AudiologyAUDIOLOGY
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
ColonoscopyColonoscopy
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
Flexi SigmoidoscopyFlexi Sigmoidoscopy
0
5000
10000
15000
20000
25000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP 0
7D
EC
07
MA
R 0
8JU
NE
08
SEP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SEP
11
DE
C 1
1M
AR
12
JUN
12
SEP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
Cystoscopy
Cystoscopy
0
5000
10000
15000
20000
25000
30000
35000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
Gastroscopy
Gastroscopy
0
10000
20000
30000
40000
50000
60000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
KEY: Blue = Activity
Green = Number of patients waiting
All 15 testsAll 15 key tests
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
JUN
E 0
6S
EP
T 06
DE
C 0
6M
AR
07
JUN
E 0
7S
EP
07
DE
C 0
7M
AR
08
JUN
E 0
8S
EP
08
DE
C 0
8M
AR
09
JUN
09
SE
PT 0
9D
EC
09
MA
R 1
0JU
N 1
0S
EP
T 10
DE
C 1
0M
AR
11
JUN
11
SE
P 1
1D
EC
11
MA
R 1
2JU
N 1
2S
EP
12
DE
C 1
2
Just do more!!
Life in Diagnostic Services?
1 – Data include equipment in hospital only. 1 – Data include equipment in hospital only.
PET CT, CT, MR etc
Massive capital costs to run just 40 hours a week
Possible to extend the day and work 7 days
May reduce need for new equipment
National Audit Office Report 2011
Managing high value capital equipment in the
NHS in England
• MR, CT, RT linacs
• VFM in purchase &
maintenance
• utilisation
• cost & performance data
Tools to effect change
• Accurate data: activity, capacity, reporting times
• Communication with commissioners → £!
• Communication within trusts: clinical &
managerial → £!
• Guidelines: NICE, collegiate etc
• Policy drivers: Stroke, Cardiac, Cancer, Paediatric
The New Vocabulary
Choice of
diagnostics
World class
commissioning
Tariffs 18 weeks
NICE guidance etc
Cancer targets
SHAs & PCTs
The NHS
GP Commissioning
Any Qualified
Provider
NHS
Commissioning
Board
QIPP
quality
improvement
productivity
prevention
Health & Wellbeing
BoardsNICE
Quality
Standards
Nothing about me
without
me
Cancer targets
Choice
Outcomes
framework
New NHS Structure
Monitor
Health and Social
Care Information
Centre
Department of Health Care Quality
Commission
HealthWatch England NHS Commissioning
Board
Clinical
Senates
Clinical
Commissioning
Groups
Local
Authorities
Providers
Suggested Way Forward
• Engagement of all stakeholders, providers & users
• Set expectations
• Patient choice very powerful
• Modelling with “pathfinder pilot sites” &
benchmarking
24/7
Extended Day +/- 7/7Diagnostics
Tertiary Care
In Patient
A&E
Stroke Strategy
Primary Care Increased Access
Patient Choice
Secondary Care delivery – Out Patient
Specialist Care
Service delivery model
The biggest challenge maybe our staff
Negotiation & influence
• Evidence for change
• Leadership, from above and within departments
• Enable rather than enforce culture shift
• Terms and conditions, contracts & employment law
Expected Benefits
• Improve primary & secondary care integration
• Share best practice
• Improve training out of hours
• Maximise capacity of current assets between
providers
• Reduce current inefficiencies & cost (in some
areas…..)
Rationale for a phased approach
Phase 1 - Urgent/Emergency & Inpatient Care
• Accident & Emergency
• Obstetrics & Gynaecology
• Trauma & Orthopaedics
• ITU & Anaesthesia
• Cardiology & Acute Medicine
• General Medicine
• Paediatrics
Build on Phase 1
Phase 2 - Elective & Outpatient Care
• Other specialties with large elective/outpatient workload
• Move from: extended week day work
weekend in patient
weekend out patient
? Ultimately no difference across 7 days
Co-dependant services
Transport, pts & staff
Domestic support &
social services
Childcare, staff & pts
Anaesthesia Monitoring VentilationECG Echo/Contrast Catheter LaScan
one cardiac patient . . . 10-day hospital stay . . .
…….six departments . . . 105 healthcare professionals
7 day pathways…