NHS gooroo blog

Posts Tagged ‘outpatients’

The genuine, externally-driven demand for healthcare is remarkably stable. But inside the NHS it doesn’t feel like that; managers are constantly responding to new pressures.

Sometimes it is a genuine and sudden spike in demand: an outbreak of flu for instance. Sometimes demand steps-up because of something the NHS has done (like start a new screening programme), which should be predictable.

But most of the time, in most services, nothing really changes very much. And yet the fire-fighting continues.

Why?

Let’s try a few scenarios and see if any of them sound familiar:

Scenario 1: The responsive clinic

The consultants’ clinic sessions haven’t changed in years. Nor have the clinic templates. The Choose & Book ‘polling ranges’ were set years ago to meet 18 weeks, and haven’t changed since.

Every now and again, staff notice that all the clinic slots have filled up so there’s nothing available on Choose & Book. They beg a willing consultant to run an extra clinic in 2-3 weeks time, and it fills up quickly with new Choose & Book patients. That takes the immediate pressure off, but patients are still booking right up to the end of the polling range.

Scenario 2: The helpful orthopods

Waiting times are a long-standing problem for orthopaedic inpatients, but the orthopods are usually quite flexible and manage to keep on top of it. Whenever the TCIs for the coming month are looking set to breach, the consultants manage to run some Saturday morning lists and avoid the crisis.

It costs an arm and a leg in overtime and bank staff, and the consultants are paid handsomely for the extra sessions, but it keeps a lid on it.

Scenario 3: The pragmatic plan

The operational managers know how many consultants they’ve got, how many sessions they’ve got, and how many cases they do in a session. So they multiply all that up, then that’s their plan for next year. Yes, some services are struggling with 18 weeks, but there’s no point in promising the commissioners extra activity when you don’t have the resources.

The solution

All those scenarios have one thing in common: baseline capacity is not based on demand.

There will always be some form of mismatch between capacity and demand, because capacity comes in chunks (consultants, sessions, beds) and demand is more continuous. Over time, the gap between capacity and demand will drift, until after a few years it becomes quite pronounced.

The result is that some elective services have a steadily growing waiting list (and periodic waiting times crises, tackled with expensive ‘extra’ sessions, as they bump along under the target). Meanwhile, other elective services have a steadily shrinking waiting list and either run out of patients or (more likely) slacken off their activity by running short sessions.

The solution, obvious as it may sound, is to align baseline capacity with recurring demand. Then those expensive ‘extra’ sessions are only needed for genuine non-recurring work, and you can pull resources out of any areas that are quietly enjoying a bit of slack.

It isn’t rocket science, but it is fiddly because you have to take a lot of things into account. It’s best to let a professional model like Gooroo Planner take care of it all for you.

You have, I hope, just signed-off with commissioners your plans for 2013/14. This is the perfect time to cross-check them. You’re going to need an internal plan you can believe in, based on what you really think is going to happen to demand, taking account of the knock-ons from outpatients to electives, and broken down week by week so you can meet your objectives all the time and not just at year-end.

Get in touch on info@nhsgooroo.co.uk and we’ll be happy to drop in and show you more. If you decide to go ahead, we can cross-check your plans as part of the initial induction programme.

A clued-up 18-weeks manager put me on the spot recently. We manage patient bookings according to their position on the whole 18 week pathway, she said. How do you model that?

My first answer was the usual one: it’s best to model each stage of the pathway separately. That way you get systematic management and planning at each step, and the outpatient booking department isn’t tempted to pass on its waiting time problems for the inpatient department to solve later.

Ah, she said, but we’re a small Trust, and we just have one booking office for all stages of the pathway. What you say is fair enough if all patients follow the same pathway; but what if some have a diagnostic stage and some don’t? Then modelling each stage separately won’t work because, at the inpatient stage, the post-diagnostic patients are much closer to 18 weeks than the others.

Well, that was a tougher question, and I didn’t have an answer to hand. Multi-stage, multi-strand pathways would be tough to model properly (taking into account clinical priorities, cancellations, booking rules, etc) and I’m not aware of anyone having done it. But it’s a good question and it deserves an answer, and after thinking about it I think the answer is this.

Booking

The scenario we are talking about is:

Let’s start with the practicalities of managing patient bookings on this pathway. The outpatient stage is a genuine single-stage booking process, and is directly suitable for good booking techniques that achieve 100 per cent slot utilisation, shorter waits, protected clinical priorities, and minimised disruption.

Then at the diagnostic stage, patients can be added to the waiting list with their original referral date, and flagged if they suffered cancellation in outpatients. This ensures that those who have already waited longest are booked first, and that previously-cancelled patients receive preferential treatment (and have capacity set aside for them). Apart from that, the diagnostic stage can also be managed as a straightforward single-stage booking process.

The inpatient stage is more complex, because the major pathway split at the diagnostic stage means there are two quite distinct classes of routine patient, with quite different waiting time histories. Nevertheless, if the inpatient stage is managed using a partial booking system and patients are added to the waiting list with their original referral dates, then I think it can also be managed as a straightforward single-stage process.

Under a partial booking system, appointments are only issued a certain number of weeks ahead, so those patients who bypassed the diagnostic stage will wait a few weeks before being given their appointments, whereas patients who had a diagnostic will be given appointments soon after being added to the inpatient list. This restores evenness to the two halves of the pathway, and allows the 18 week target to be achieved across both parts of the pathway, with the largest possible total waiting list.

Planning

What about planning? When it comes to planning future activity to achieve the 18 week operating standard, the outpatient stage can be modelled as a single stage, as above. After that point, if you do want to model the split pathway, I think it makes sense to split it (for planning purposes only) all the way to the end, so that it looks like this:

So, for example, your planning might involve working out the activity, capacity and cost required to achieve 90 per cent treated within:

• 6 weeks, for outpatients
• 6 weeks, for diagnostics
• 6 weeks, for post-diagnostic inpatients
• 12 weeks, for non-diagnostic inpatients

That way, you are planning to achieve the overall 18-week target, but still taking advantage of the longer waits available on the non-diagnostic inpatient path.

Incidentally, whilst it is fine to split the pathway like this for planning purposes, it is usually better to avoid splitting an operational booking system. The differences in waiting times between one consultant and another are bad enough, without adding any further splits.

In elective services, the worst sin of all is under-utilising the valuable resources you have available. It costs you financially (both as lost income and incurred expenditure), and it pushes up the waiting list and waiting times. So hospitals generally try to avoid this sin, and fill capacity up as much as possible.

However, you find that unpleasant things start happening as you push utilisation up towards the magic 100 per cent mark. Suddenly you are faced with lots of questions, such as:

1. When all your appointment slots are full, how do you book urgent patients at short notice? How many slots should you hold back for them?
2. Should those urgent slots ever be used for non-urgent patients?
3. What should you do if an urgent referral comes in, but still no slots are available?
4. When patients are cancelled by the hospital, should they get preferential treatment when you rebook them?
5. Are the answers to these questions different, depending on whether you run a fully- or partially-booked appointments system?

The good news is that there are answers to all these questions, which means that you can utilise your elective capacity at 100 per cent. In fact 100 per cent utilisation is so desirable, that we took it as a basic assumption when beginning our research into the best tactics for booking elective patients.

So what are the answers to the questions above?

1. Yes, you should reserve some appointment slots for urgent patients. It’s worth getting this right, because the worst performance comes from having too many. You can calculate the right number using our Booking Rules Calculator, which is available free of charge just after you login to Gooroo.
2. In a fully-booked service, it is better to rebook cancelled routine patients into urgent slots when necessary. But in a partially-booked service this is not necessary. (Newly-added routine patients, however, should just get the next empty routine slot.)
3. If an urgent patient needs to be booked at short notice, but there are no slots available, then you should cancel the routine patient who will be least inconvenienced.
4. These cancelled routine patients should get preference over new routine patients when you’re dishing out the next available slots. In a fully-booked service they can access urgent slots too.
5. As we have seen, the best tactics are slightly different for partially booked services. The best number of reserved urgent slots is also different.

Our research (which studied over a million years of simulated bookings) threw up some other results too.

Firstly, it is good to be as precise as possible about how long each urgent patient can safely wait, and book them right up to their clinically safe limit. This finding was expected from the work we conducted on waiting lists in the 1990s, but it was good to have it confirmed in simulation.

Secondly, fully-booked services perform almost as well as partially-booked services, if (and it’s a big if) the level of disruption is the same. Of course the whole point of running a partially booked service is to reduce the number of cancellations caused by staff taking annual leave, so there should be less disruption under partial booking (and so even better performance compared with a fully-booked one). (Set against that, you have greater certainty to patients in a fully-booked service, so take your choice…)

Thirdly, it doesn’t make very much difference whether you can arrange for any potential long-wait patients to accept a rebooking, if slots remain empty at short notice. This counter-intuitive result holds both for waiting times on their own, and for a basket of measures that takes disruption into account. Why? Simply because in a well-managed service there should be very few opportunities to rebook patients into short-notice slots; the slots are generally full.

Fourthly, there is good news on offering a choice of bookings to patients. You can offer slots in up to three different weeks without significant impact on waiting times or other aspects of performance. It might even reduce your DNA and rebooking rates.

Finally, we looked at another booking technique that is used in some hospitals: rippling. What is rippling? Imagine you have an urgent patient to book, but no empty slots that are soon enough. So you cancel the least-inconvenienced routine patient. Now what do you do with this cancelled patient? You could rebook them into the next available slot, which might be a long time in the future. Or you could cancel another routine patient in a couple of weeks time to make space, then cancel another a couple of weeks after that, and so on until you reach the next empty slot. So lots of patients are delayed a little, instead of one patient being delayed a lot.

Now that you’ve got your head around all that, you can forget it. Rippling isn’t a good idea. The disruption caused to patients by all those rebookings will always outweigh the benefits of shorter individual delays. “But what about my waiting time targets?”, you ask? Well, that is what the allowance is for, that lets 5 or 10 per cent of patients wait longer than the time limit.

You can find full details of this research in our Research White Paper 4, available after login here. And you can get practical experience using our simulator training program: SimTrainer (the first four levels are free of charge).

A new video shows the power of better patient scheduling to reduce waiting times. It shows waits falling from 20 weeks to 14, just by managing bookings better.

What made the difference?

• the right number of slots was reserved for urgent patients
• urgent patients waited as long as was clinically safe for them
• only genuinely urgent patients were declared urgent

The video tells the story by itself. So let’s look instead at something the video doesn’t cover…

Follow-up outpatients

Imagine this: You are booking referrals into outpatient slots. Every routine patient gets the next available slot. You’re busy, and all slots are fully booked up for the next few weeks. Then an urgent referral arrives, and the patient needs to be seen quickly. But all the early slots are full. The only way to squeeze them in is to cancel someone else. But who?

In the video we assumed that a routine first appointment would be cancelled – whoever is least inconvenienced by the delay. But many hospitals prefer to cancel follow-up patients instead (usually two or three, in fact, because follow-up appointments tend to be shorter than new appointments). This lets them make space for the urgent patient, without putting extra pressure on their 18-week waiting time target by delaying a first appointment.

So which is better? If you have to cancel patients, should you cancel one routine first appointment, or two (or three) follow-ups?

To answer this, we need to look at follow-ups more closely. A follow-up patient should (if referred appropriately) be someone who needs to be seen during a specified window of time: for instance 2-4 weeks, or 5-8 months, after their previous appointment.

The first thing to point out is that some patients are followed-up unnecessarily, so the first priority should be to ensure that patients are only followed-up for the right reasons. Clogging up the clinic with unnecessary follow-ups is a waste of clinicians’ time, and the patients’.

Now let’s look at this time window. If the patient could just as well be followed-up after 8 months as 5, then it makes sense to go for 8 months. Why? Because it reduces the number of follow-up appointments in any given year, releasing capacity for other work. Otherwise you end up seeing patients more often than necessary, which again wastes everybody’s time.

But there is a consequence. Once the patient reaches the 8 month mark, they really do need to be followed-up now. In effect, they are clinically urgent. So we can’t cancel them. We should cancel a routine first appointment instead, if we have to.

So the story told by the simulation video is the right one. We should cancel routine first appointments, not follow-ups, if we need to make space for urgent referrals. As the simulation shows, it is possible to do this and keep waiting times to a minimum.