Cardiff and Vale University Health Board (UHB)

Responses to the action points from the Public Accounts Committee on 11^th March 2019 regarding the management of follow-up outpatients

The results of the recent internal/clinical audit work undertaken regarding outpatient follow up appointments

The Health Board undertakes clinical audits as part of both a national and local programme, details of which are below.

National Clinical Audit: Cardiff and Vale UHB participate fully in the National Clinical Audit and Outcome Review programme which consists of 39 audits undertaken across the UK. These audits review care against national guidelines, more commonly NICE guidelines, and will incorporate numerous key performance indicators including some elements of care provided in an outpatients setting and in some cases time to referral and treatment. All National Audits results are published nationally. Below are a few examples of where outpatient activity is reviewed as part of this programme.

National Oesophageal Gastric Cancer Audit	Includes  waiting times for treatment, Where patients present at the point of diagnosis ( primary care, emergency admission)
National Heart Failure Audit	Includes post discharge follow up
National Bowel Cancer Audit	Determines where patients are presenting at diagnosis (Routine screening, primary care, emergency admission)
National Diabetes Audit	Audits compliance with measurement  of Key care processes  undertaken almost exclusively  in outpatients and in Primary Care
National Epilepsy 12 Audit	organisational audit with service descriptors including provision of epilepsy clinics, referrals to tertiary services and patient advice services
National Neonatal Audit	follow up at two years old

Local Clinical Audit: The UHB has a dynamic programme of local clinical audit aligned to our clinical quality and safety priorities. Clinical Audit is by definition a measurement of care against best practice guidelines. Most local audits will review local practice against national guidelines which will incorporate multiple performance indicators, many will include elements of care provided in primary care, including referrals into secondary and tertiary services, outpatient departments and unscheduled care. Below are several examples of audits that have been reported in the previous 2 years with an example of the specific indicators that relate to outpatient / unscheduled care activity.

Immunisation  status  of children aged 0-5 who present  to the emergency department	Audit of procedures in place to raise immunisation status  with parents / guardians
Service provided  to children  with Trisomy 21	Review of annual reviews and measurement of key indicators
Management of malignant melanoma	To determine if the care delivered was in line with NICE guidelines NG14 including post review correspondence with the patients GP
Investigation Diagnosis and management  of Adrenal Insufficiency	Review of care in line with Endocrine Society Guidelines including referral to endocrinologist.
Compliance with NICE guidelines CG142 in the management of Autistic Spectrum Disorder in adults.	The audit measured compliance with the guidelines as well as ensuring that appointment letters include an invitation for  family or carers to attend the appointment with the patient
Missed colorectal cancer rates following colonoscopy	The audit included review of patients  booked appropriately for ongoing polyp surveillance
Colorectal Cancer Surveillance	Audit of 1, 3 or 5 year surveillance
Audit of managements of newly diagnosed HIV	The audit includes compliance with monitoring of patients against the British HIV Association  guidelines

Confirmation as to whether all optometrists located in the Cardiff and Vale Health Board area will be able to refer patients for a consultant appointment electronically when the system is rolled out during the first quarter of the 2019-20 financial year

The Health Board has been undertaking a pilot for e-Optometry referrals. This initially commenced in two practices and has now been extended to 14 practices. To date, we have received in excess of 2000 electronic referrals into ophthalmology. The next step is roll-out of e-Optometry (Referral) into the remaining 44 Optometric practices in Cardiff and Vale. We have received Welsh Government funding to assist with this and we can confirm the plan is to complete the rollout by the end of June 2019. With this funding, we are also implementing a community based ophthalmology service for glaucoma, medical retina and diabetic retinopathy. This will be delivered from 6 optometry practices across 3 localities but will manage all referrals. The IT infrastructure in each of the practices will allow the practice to electronically refer into secondary care and will be in place and operational post tender award in the summer of 2019.         

The number of out of area patients currently waiting for an outpatient referral together with a breakdown of the service areas.

The number of out of area patients waiting for an outpatient appointment will change daily. The numbers below reflect the total number of pathways and not individual patients i.e. the Health Board records and reports the data by the specialty under which the patient is treated. An individual patient may be counted more than once if they are waiting for an appointment in more than one specialty. As at 21^st March 2019, our system shows:

· 5,671 out of area patients waiting for a new outpatient appointment

· 60,786 out of area patients waiting for a follow-up outpatient appointment

The following table details the number of out of area patients waiting for a follow-up outpatient appointment for the specialties highlighted by the Auditor General:

Specialty	Total number of out of area patients waiting for a follow-up appointment
Trauma & Orthopaedics	6,195
Ophthalmology	4,632
General Surgery	5,209
Cardiology	5,218
ENT	1,692
Urology	1,818
Paediatrics	3,967
Gynaecology	3,127
Dermatology	989
Gastroenterology	611