Cornwall’s health community has been experiencing difficulties with their Outpatient (OP) Services System, resulting in overly long waiting times for appointments with consequential risks to patients. Previous improvement programmes were unsuccessful, resulting in a worsening financial situation. To help with this the Kernow (Cornwall) STP, with backing from NHS England under their QIPP programme, have appointed SCW’s System Transformation team to help research, develop and instigate a transformation programme. The initial aim of the programme is to identify key opportunities to reduce OP waiting times and generate efficiency savings across the service.
Health provision in Cornwall and the Isles of Scilly (CIOS) faces many particular challenges. The county has a higher profile of retirees than the rest of the country and the population more than doubles during the summer months. Because many of the jobs in CIOS are seasonal and reliant on tourism, there is less job security, leading to higher rates of homelessness and alcohol abuse.
CIOS OP facilities are located across 35 different sites in the county, as well as using Plymouth hospital in neighbouring Devon. OP waiting times in CIOS have been consistently longer than their required target, which presents potential threats to patients. This has been caused by funding and capacity issues as well as system inefficiencies. It was recognised that advances in technology could provide opportunities for new ways of working, but these would need further investigation.
The continued pressure and extended waiting times, led to Kernow STP coming under increasing scrutiny and review from the CQC, Health and Safety Executive and NHS England. SCW were appointed by Kernow STP and NHS England to analyse and evaluate the current system and to make recommendations for a transformation programme to significantly reducing OP waiting times.
SCW’s Systems Transformation team obtained information on all elements of current performance by each OP facility, as well as additional relevant data from the neighbouring Devon Hospitals on Cornish patient usage. This exercise also included exploratory meetings and discussions with key stakeholders at Royal Cornwall Hospital Trust, Cornwall County Council, the Referral Management Centre and a number of local community providers.
The resulting datasets were triangulated into a comparable format and then benchmarked using RightCare data against data from 10 similar CCG’s across England. The analysis identified nine OP clinical specialist areas for investigation: Cardiology, General Surgery, Breast Surgery, Gynaecology, Clinical Haematology, Pain Management, Dermatology, Ophthalmology and Trauma Orthopaedics.
The SCW analysis then looked at nine different metrics for measuring OP service provision. These were:
First attendance rate per 1,000 population
First to follow up ratio
Rate of outpatient procedures undertaken
Rate of discharge at first attendance
Did Not Attend rate
Hospital cancellation rate
Patient cancellation rate
The team analysed how the clinical specialities were performing in each of the different areas. This information was then presented as a ‘Heat Map’ which identified the key areas where each specialisation needed to make improvements and focus their resources to reduce waiting times.
Analysis was also undertaken on the network of OP facilities to assess which services are, and will be, most required based on population profile at each geographic location. This enabled new pathways to be mapped out to optimise the use of facilities and required resources. To deliver the transformation programme (named ‘Outpatient Leadership Live’) a Programme Board was created and a Programme Director appointed from Kernow STP. SCW provided the board with our transformation plan recommendations which included OP pathway re-design, contractual changes with providers and suppliers, as well as actions to encourage the improvement of patient self-care in CIOS as a whole.
Although the programme has only just begun the implementation stage, it is expected to deliver on the key requirement of increased capacity for outpatient services through pathway redesign and different ways of working, and to significantly reduce OP waiting times.
The transformation programme is anticipated to generate an estimated saving of £160k in Q4 of 2018/19 and an additional £600k in 2019/20.
Better OP pathway management across the county is expected to provide further efficiency gains and better planning of OP clinics which could save substantial amounts in consultants travel expenses and make better use of their time.
With the remote location of the Isles of Scilly, there is an opportunity to test the implementation of virtual consultations using video conferencing facilities between the mainland and the islands’ surgery. This could provide further savings in travel costs as well as better use of consultants and patients time.
A standard set of measurable KPIs has now been established based on the nine previously identified metrics and the outcomes of the programme are now fully supported by a structured governance framework.
As a result of SCW’s recommendations, we have been asked to return and assist as consultants in the implementation of the programme going forward.