Cardiff & Vale University Health Board
Response to the Public Accounts Committee inquiry into the Management of follow-up outpatients across Wales.
Introduction
1. Cardiff and Vale University Health Boardwelcomes the opportunity to contribute to the Public Accounts Committee inquiry into the Management of follow-up outpatients across Wales. This paper provides the Health Board’s written response to the areas highlighted by the Committee as part of their inquiry, namely:
· The factors that are creating the demand for follow-ups
· What has prevented Health Boards from making progress in tackling the issue
· Where Health Boards have been able to secure improvement, what have they done to achieve this
· The latest waiting time statistics
Background
2. As a result of growing national concerns relating to the management of follow-up outpatients, the Wales Audit Office undertook an initial review in 2015-16 and a follow-up review in each Health Board in 2017-18 to help define the extent of the challenges being faced and the progress that has been made in addressing them. The Auditor General published a summary report for Wales and individual Health Board reports in October 2018 outlining his findings from the follow-up review.
3. In summarising the position across Wales, the Auditor General found that health boards had made some progress in response to recommendations made by the Auditor General in 2015-16, but the pace and impact on reducing the backlog of delayed follow-up appointments is limited, with significant variations between specialties and health boards across Wales. Since 2015, the number of patients on the follow-up outpatient list and the number of patients whose appointment has been delayed have substantially increased.
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The factors that are creating the demand for follow-ups
4. In 2017/18 there were just over 550,000 outpatient attendances across seven Cardiff and Vale University Health Board hospital sites, over two thirds of which were follow-up appointmentsi.
5. Follow-up care forms an integral part of a patient’s pathway in supporting the diagnosis and management of conditions or monitoring and managing patients with chronic disease or lifelong conditions. The Royal College of Physiciansii outline the purpose of follow-up outpatient care as follows:
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6. The basic model for delivering outpatient services has remained relatively unchanged over the years i.e. face-to-face consultations with a specialist in a hospital clinic setting. Current and anticipated changes in demography, science and technology, patient expectation and workforce mean that this traditional approach is not fit for purpose. While some follow-ups outpatients are clinically required, a large proportion is unnecessary or can be undertaken using an alternative model of care.
What has prevented health boards from making progress in tackling the issue?
7. The single biggest challenge for Cardiff and Vale University Health Board has been the recording of and accuracy of its follow-up outpatient data.
8. Patient Management System (PMS), an Information Technology system specific to Cardiff & Vale University Health Board, is used to manage and report on follow-up outpatient data. The system was historically designed to primarily manage and report on patients on a Referral to Treatment Time pathway, resulting in the systems functionality not being conducive to accurate data capture for follow-up outpatients. In their initial report in 2015iii, the Auditor General highlighted that the Health Board’s outpatient follow-up waiting list contained a number of erroneous inclusions. These were as a direct result of its system issues.
9. In line with national guidance, the Health Board records and reports the data by the speciality under which the patient is treated i.e. a patient may be counted more than once if they are being followed-up in more than one specialty. In May 2014, there were approximately 778,000 patients on the Health Board’s follow-up outpatient waiting list, many of whom did not have a target date recorded of when the clinician had determined they should be seen.
10. The scale and nature of the issues meant the initial focus for the Health Board was to more accurately determine the extent of the volume of patients who were waiting for a follow- up and those who were overdue their planned follow-up outpatient appointment.
11. The Health Board developed an automated validation approach to improve the data quality, engaging with clinicians and ensuring the appropriate controls were in place to mitigate the risk of ‘off-listing’ patients with a genuine clinical need for a follow-up appointment. This approach halved the numbers of patients on the original follow-up waiting list – to just under 400,000 in March 2018 but 51% of those still did not have their clinically agreed target date recorded.
12. Good quality data underpins the delivery and transformation of effective follow-up care and improving data quality has remained a key component of the Health Board’s strategy.
Where Health Boards have been able to secure improvement, what have they done to achieve this?
13. In 2015-16, the Auditor Generaliii concluded “that from a difficult starting point, Cardiff and Vale University Health Board is taking appropriate action to identify the volume of its outpatient follow-up need but too many patients are delayed, the trend is worsening and it needs to do a lot more to develop sustainable follow-up services”.
14. In response to the Auditor General’s report in 2015, the Health Board broadened its approach, moving to a more encompassing programme of work. We developed and have subsequently refreshed our Follow-Up Outpatient Improvement Strategy, comprising of three main components:
· Identifying specialities and clinical conditions of higher risk
· Improving the quality of our data
· Transforming outpatients
Identifying specialities and clinical conditions of higher risk
15. In 2015, the Auditor Generaliii found that ‘the Health Board had taken a pragmatic approach to determining the volume of outpatient follow-up demand but it needs to better understand clinical risks to patients.’ Working with our clinicians, the Health Board undertook a specific piece of work to identify the specialties and / or clinical conditions that are of a higher clinical risk in relation to follow-up delays. The Clinical Risk Assessment identifies the speciality, specific clinical condition and the potential harm that may be caused because of a delay. The assessment is used to focus improvement action, resources and scrutiny. Cardiff and Vale University Health Board’s systematic approach for identifying specialities and conditions presenting the greatest risk of harm has been highlighted as good practice by the Auditor General in his 2018 summary report for Wales.
Improving the quality of our data
16. The Health Board has continued to build on the significant work undertaken to improve levels and quality of information. There are two elements to this:
· To stop erroneous additions to the list - by reducing and eliminating patients being recorded on the system without a target follow-up date and those being recorded requiring a follow up appointment when it has been clinically determined they do not require one. This has required changes to the functionality in PMS.
· To clarify the correct status of the patients recorded on the current waiting list. This requires automated, clerical and clinical validation.
Our overall approach to improving data quality remains a clinically informed approached to mitigate the risk of ‘off-listing’ patients with a genuine clinical need for a follow-up appointment.
17. The Health Board has seen further improvement in 2018-19 in improving the quality of its outpatient follow-up information. The work undertaken has realised a continued reduction in the overall volumes – from just under 400,000 in March 2018 to 316,000 in January 2019, a 20% reduction. The work has also further clarified the clinically agreed target date for a large volume of patients.
Table 1: Reported outpatient volumes comparison – March 2018 versus January 2019
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Category |
January 2019 |
March 2018 |
(Reduction) / Increase |
% |
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Number of patients where there is no recorded target date |
57,672 |
202,013 |
(144,341) |
-71% |
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Number of patients where there is a recorded target date |
257,939 |
193,631 |
64,308 |
33% |
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Total follow-up waiting list |
315,611 |
395,644 |
(80,033) |
-20% |
Source: Monthly follow-up outpatient submission to Welsh Government
18. Whilst the work undertaken has realised a continued reduction in the overall volumes on the waiting list, further clarification of the clinically agreed target date has led to an increase in the volume of patients delayed past their clinically agreed target date from 134,000 in March 2018 to 190,000 in January 2019 and specifically those patients experiencing 100% delays i.e. patients waiting twice as long as they should be – with 124,000 patients reported in this category in January 2019 compared to 76,500 in March 2018.
19. The intelligence surrounding the ongoing data quality improvement work suggests that both the volume of patients on the outpatient follow-up waiting list and those reported as delayed are still materially over-stated. Work on this, therefore, continues with further improvement anticipated in the next month.
Transforming outpatients
20. Notwithstanding the data quality issues, the Health Board acknowledges that there are a significant number of patients that require more timely access to the follow-up care they need and any delay to this is unacceptable. Whilst our annual activity demonstrates there is significant capacity for follow-up care within our current system, growing demand and poor patient experience means that we need to move away from the traditional hospital-based outpatient model of care and transform the way we provide follow-up care.
21. Outpatient transformation is being driven at a local level through the Health Board’s Transformation Programme, with our priorities aligned with the national priorities from the National Planned Care Programme Board. Our work is focused on improving patient access, experience and outcomes through transforming the way outpatient consultations are delivered, establishing a pathways approach, re-thinking the location (closer to home) and enhancing the role of patients. This work is underpinned by creating a digitally enabled organisation and workforce and changing and modernising professional roles.
22. Progress has been made in a number of areas, including:
Healthpathways: The Health Board went live with Healthpathways, an internet based repository of clinical pathways and guidance, in February 2019. To date, 24 local pathways of care have been collaboratively developed by primary and secondary care. These focus on the management of conditions within Primary Care with clear guidelines on referral to specialist services at the appropriate point. The benefits include: easily accessible and intuitive locally agreed information for clinicians in one place; rapid localisation of pathways of care; and reducing unnecessary follow up appointments as a result of guidance of when testing is not needed or can be spaced out.
Fully Automated booking and text reminders: The Health Board has partially rolled out two systems to improve the booking experience for patients, to reduce the number of missed outpatient appointments and increase the re-utilisation of cancelled appointment slots. The first is the Fully Automated Booking (FAB) system, a system based on automated patient letters and telephone reminders. This has more recently been complemented by a text reminder service.
Patient Recorded Outcome Measures (PROMs): Patient Reported Outcome Measures (PROMs) are a systematic way for patients to tell clinicians about their care, experience and health status. They help us monitor a patient’s progress and provide strong evidence on the effectiveness of care and treatment. The Health Board’s use of PROMs in orthopaedics supports a virtual review from six months, helping to reduce face to face follow ups.
Patient Knows Best: The Health Board’s Audiology team were recently honoured with the National Planned Care Programme’s Sustainability Award for implementation of Patient Knows Best, an e-health solution which empowers patients to manage their care and enables professionals to share information. The benefits include reducing unnecessary hospital appointments and provision of a library of resources. Plans are also in train to implement Patient Knows Best in urology for patients diagnosed with prostate cancer.
Virtual fracture clinics: The Health Board is progressing with the introduction of virtual fracture clinics, an alternative to conventional fracture clinics, to manage certain musculoskeletal injuries. The benefits include: Improving patient experience of their fracture management by bringing first line treatment closer to home; patients receive protocol driven, evidence based treatment which is standardised to ensure an equally high standard for all patients; and patients only attend hospital if they need specialist care.
Alternative models of care Ophthalmology: With the support of Welsh Government funding, the Health Board is progressing implementation of community based Ophthalmology services to assess and manage patents whose eye conditions are at low risk of deterioration who are either referred by primary care for assessment or discharged from secondary care ensuring a safe equity service is delivered closer to patients home.
23. The Health Board is taking steps to modernise its outpatient services and, with its transformation programme, is well placed to progress further.
Latest waiting time statistics (by treatment specialty)
24. The Health Board submits a monthly return to Welsh Government on follow-up outpatients. The latest census point is 31st January 2019. Appendix 1 details the total waiting time statistics for the Health Board and for the treatment specialties highlighted by the Auditor General.
Conclusion
25. From a difficult stating point in 2014, the Health Board can demonstrate continuous improvement for follow-up outpatients.
26. The single biggest constraint for the Heath Board has been the impact of the Patient Management System issue on our level and quality of data. Since 2014, we have seen significant progress in addressing this issue, although there is further work to be done in ensuring we have good quality data to underpin the delivery and transformation of effective follow-up care.
27. Cardiff and Vale University Health Board’s has a systematic approach for identifying specialities and conditions presenting the greatest risk of harm. This has been highlighted as good practice by the Auditor General.
28. The Health Board has made some progress with transforming and modernising outpatient services but has further work to do. Through its transformation programme, the Health Board is well placed to continue to transform the way we deliver follow-up care. This work is aligned with National Planned Care programme follow-up priorities.
29. In his follow-up review in 2017-18, the Auditor Generaliv concluded that ‘the Health Board has made progress in addressing the recommendations made in our 2015 report and, with the Outpatient Transformation Programme….is well placed to meet all recommendations.’
i. Stats Wales, Outpatient activity: Outpatient attendances by organisation and site
ii. Royal College of Physicians, 2018, Outpatients: The future – Adding value through sustainability
iii. Wales Audit Office, October 2015, Cardiff and Vale University Health Board – Review of Follow-up Outpatient Appointments http://www.audit.wales/publication/cardiff-and-vale-university-health-board-review-follow-outpatient-appointments
iv. Wales Audit Office, October 2018, Review of follow-up outpatients – assessment of progress – Cardiff and Vale University Health Board http://www.audit.wales/publication/cardiff-and-vale-university-health-board-review-followup-outpatients-assessment