Challenges and improvements in diagnostic services across seven day services
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Prof Erika Denton, National Clinical Director for Diagnostics. Slides from Erika's presentation at the 7 Day services events in West Midlands 11th June and East Midlands 12th June, 2014.
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Challenges and improvements in diagnostic services across seven day services
- 1. The Challenges and Improvements in Diagnostic Services across 7 Day Services Prof Erika Denton, National Clinical Director for Diagnostics West Midlands June 11th 2014
- 2. • The NHS and diagnostics • National data • Geographical variation • 7 day & 24/7 working • Diagnostic service improvement work
- 3. The aim for all healthcare….. To deliver appropriate, good quality, cost effective care co-ordinated across primary and secondary care
- 4. The five pillars of diagnostics 10% of NHS spend, £8 billion 1 billion tests pa Genetics Cyto&moloeculargenetics Imaging egx-Ray,CT,MRI,ultrasound Endoscopy inccolonoscopy Physiology EgAudiology,Resp,Cardiac Pathology Blood,Cellular,Infection The five pillars of diagnostics
- 5. Why does diagnostics matter? Key examples: • Pathology, imaging & endoscopy for cancer diagnosis • Timely brain imaging enables thrombolysis and doubles number of stroke patients who walk, from 1/3 to 2/3 • Interventional radiology for post partum haemorrhage vs hysterectomy, in limb ischemia vs amputation • Sleep studies initiate treatment to prevent morbidity & mortality • Genetic testing enables monitoring or intervention to avoid early death & hereditary transmission • Long term condition management of diabetes, rheumatological disorders etc
- 6. NHS Outcomes Framework Commissioning to support delivery of 5 domains: • Domain 1 To prevent people from dying prematurely • Domain 2 To enhance the quality of life for people with long term conditions • Domain 3 To help people recover from episodes of ill health or following injury • Domain 4 To ensure that people have a positive experience of care • Domain 5 To treat and care for people in a safe environment and protect them from avoidable harm
- 7. Sounds simple for a CCG….? 1-3 large acute contracts, value >£50million 10 - 30 smaller inpatient and community contracts c. £1million 100s of single provider contracts or individual patient placements <£100k Cataracts General surgery A&E Trauma Maternity Comorbidities Dementia Neurology Weight management Cancer Depression Respiratory Long Term conditions Rehab Deprivation Disadvantaged groups
- 8. Specialised Commissioning • 5 groups of Service Specific CRGs • Specialised is for popn >1m, rare conditions • Directly commissioned by NHSE • Standardised structure for all CRGs
- 10. The NHS Funding Gap…
- 11. Projected Rate Of Population Growth By Age Last BirthdayGraph showing projected rate of growth of Projected populations at mid-years by age last birthday (under 60 years and over 60 years) over the next 8 years. Source: Government's actuarial department 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).
- 12. Causes Of Death, over 60s Respiratory Diseases GI Disease Mental/Behavioural CNS Disease Abnormal Findngs All Others Circulatory Diseases Neoplasms80% of death of the over 60s attributed to 3 underlying causes
- 13. Why do we have a Challenge? Because the equation… Demographics + Patient / Public Expectations + Quality Money
- 14. Rising to the Challenge? Demographics + Patient / Public Expectations + Quality Money Solution = transformational change to the current way of delivering health care
- 15. ‘Old’ vs ‘New’ change methodology Transactional change: Doing things better Transformational change: Doing better things
- 16. ‘You can’t solve a problem by using the same thinking that created it’ Albert Einstein
- 17. National Data • Equipment • DMO1 • Intervention Rates • DID • The Atlas of Variation
- 18. National Audit Office Report 2011 Managing high value capital equipment in the NHS in England • MR, CT, RT linacs • Poor VFM in purchase & maintenance • Variable utilisation • Poor cost & performance data NHS Supply chain currently reviewing existing equipment in NHS to baseline & evidence benefit of modernisation
- 19. 1 – Data include equipment in hospital only. 1 – Data include equipment in hospital only.
- 25. 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.
- 26. The Diagnostic Imaging Dataset: DID • Monthly • Direct from RIS • Every imaging event: requester, demographics, code of test etc • Report turnaround & waiting times • Link to outcomes via HES & Cancer registries? • Extending to include all diagnostics? Aim: to establish “optimum” intervention rates
- 27. DID: Chest x-ray usage by CCG Chart 1 – Rate per 1000 GP Registered Population GP Direct Access activity 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 45.00 0 50 100 150 200 250 Median Mean NHS Airedale, Wharfdale And Craven CCG Low er Quartile Upper Quartile
- 28. DID: Ultrasound usage by CCG GP Direct Access activity 0.00 5.00 10.00 15.00 20.00 25.00 0 50 100 150 200 250 Median Mean of CCGs NHS Barking And DagenhamCCG Lower Quartile Upper Quartile
- 29. Life across the NHS? Just do more!!
- 30. The NHS Atlas of Variation Looking at rate of healthcare interventions undertaken per population eg. For sleep studies 2010/11 60 fold variation between the highest PCT and lowest PCT still a 27-fold variation, when you don’t consider the top 5 and bottom 5 PCTs Similar pattern across diagnostic services
- 31. Rate of magnetic resonance imaging (MRI) activity per weighted population by PCT, 4 fold variation 2010/11
- 32. Rate of dual-energy X-ray (DEXA) scan activity per weighted population by PCT, 13 fold variation 2010/11
- 33. Rate of PET/CT activity per population, by PCT, 25 fold variation 2010/11
- 34. • Benchmarking • NHS diagnostic service improvement • Pathology • Endoscopy • Interventional radiology • 7 day services NHS | Presentation to [XXXX Company] | [Type Date]34 NHS Service Improvement
- 35. Founded in 1996 in house, by and for the NHS Over 320 member organisations Sector based reference groups Hosted by East London NHSFT Non-profit making – all membership fees support the work programme NHS Benchmarking • “benchmarking is the use of structured comparisons to help define and implement best practice”
- 36. Community services Community hospitals Urgent Care Integrated Care (new) – including older people’s commissioning Medicines Management (new) Theatres Corporate functions Benchmarking project reports & good practice guidance Mental health inpatients & community CAMHS Learning Disability (new) Acute therapies OT/Physio & SLT/Dietetics Emergency Care Radiology Older People (new) Intermediate Care
- 37. • Recurrent revenue costs per 100,000 outpatient attendances. • Median £2.57m per 100,000 OP attendances • report turnaround times for CT vary, median 2 days, range from same day - 9 days. Benchmarking examples 37 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 R033 R090 R026 R074 R040 R028 R016 R047 R068 R079 R024 R086 R051 R007 R052 R073 R025 R046 R017 R065 R015 R011 R088 R078 R083 R042 R014 R013 R036 R050 R009 R045 R030 R082 R085 R092 R010 R072 R031 R005 R071 R021 R076 R038 R075 R041 R060 R012 R054 R067 R056 R070 R003 R080 R032 R087 R059 R062 R066 R058 R069 R081 R091 R044 R027 R089 R064 RevenueCosts Total Revenue Costs for Radiology 2012/13 per 100,000 Outpatient Attendances Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile 0 1 2 3 4 5 6 7 8 9 10 R082 R065 R091 R017 R044 R021 R059 R087 R070 R052 R064 R016 R036 R058 R056 R013 R041 R062 R066 R072 R075 R077 R024 R028 R045 R032 R078 R009 R010 R043 R083 R092 R076 R027 R007 R042 R048 R067 R073 R090 R003 R033 R012 R054 R081 R038 R030 R060 R015 R069 R074 R005 R031 R050 R051 R080 R085 R086 R088 R046 R025 R068 R071 R047 R079 NumberofDays Average Report Turnaround Time in Days - CT Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile
- 38. Reporting using Voice Recognition Average 62% of examinations reported with VR 0% 20% 40% 60% 80% 100% 120% R011 R028 R052 R070 R084 R090 R013 R033 R060 R058 R003 R009 R093 R048 R077 R017 R043 R045 R078 R064 R074 R068 R007 R038 R066 R079 R082 R050 R010 R015 R005 R046 R080 R030 R031 R092 R065 R054 R069 R044 R016 R083 R073 R025 R071 R036 R059 R027 R081 R087 R047 R072 R062 R075 R056 R021 R014 R088 R042 R076 R012 R085 %ofExaminationsReportedUsingVoiceRecognitionSoftware % of Total Examination Reported Using Voice Recognition Software Teaching Large Non-Teaching Medium Non-Teaching Small Non-Teaching Community Mean Lower Quartile Median Upper Quartile
- 39. CT most extended hours availability (78%) Fluoroscopy, MRI, and Cath Lab all have availability levels at more than 50% of weekly available hours. PET, DEXA, Nuclear Medicine and Mammography have lowest hours of availability. Equipment Utilisation Rates by Modality 39 58% 51% 27% 26% 50% 25% 22% 44% 51% 78% 66% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Average % UtilisationAcross All Trusts Plain film X-Ray - total CT MRI Ultrasound DEXA Nuclear Medicine Fluoroscopy PET Mammography Catheter Laboratory / Interventional Cardiology Other
- 40. Pathology Improvement Programme From 2008 • Cytology • Histopathology • Blood Sciences • Microbiology • Phlebotomy • SHA based approach
- 41. 0 10 20 30 40 50 60 70 80 90 100 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Percentage(%) Histopathology- Average TAT in 7 & 3 days 7day TAT 3day TAT
- 42. Lessons learned • In house improvements in pathology impacted positively on whole patient pathways • Quality was improved • Turnaround times were reduced • Sustainment of the improved processes was variable • The ability of Managers and Leaders was variable
- 43. Second Phase for National Pathology Improvement • ‘Influencing the future-leadership in action’ Leadership Development Programme first in pathology now for MDTs with radiology • Exemplar site development Organisation development programme learning from those with sustained best practice and continuing to innovate and improve
- 44. Interventional Radiology: the evidence for change the evidence for change• NCEPOD on Trauma, Renal, IR & Neuro IR, AAA • NICE: UAE, NAI etc • Northwick Park Maternity Services HCC report • Birmingham Children’s Services HCC report • National Imaging Board’s reports: ‘Interventional Radiology: Improving Quality and Outcome for Patients’ ‘Interventional Radiology: Guidance for Service Delivery’
- 45. DH involvement with Interventional Radiology • Interventional Radiology (IR): ‘Improving Quality and Outcomes for Patients’ (DH, National Imaging Board 2009) • Interventional Radiology: Guidance for Service Delivery (DH 2010) • Delivering the Service: Interventional Radiology for Major Trauma Networks (DH 2010) • Towards best practice in IR – (NHS Improvement 2012)
- 46. College Guidelines: RCR (2009):Standards for providing a 24-hour radiology service Acute intervention including damage control surgery, . . . . . . . . . interventional radiology, haemorrhage control, and blood transfusion. Interventional suites should be co-located with operating rooms &/or resuscitation areas. Interventional radiology (IR) taking place within an MTC should be available 24 hours a day. Patients requiring acute intervention for haemorrhage control should be in a definitive management area (operating room or IR suite) within 60 mins of arrival.
- 47. IR Programme 2011-12: Trauma & IR Aim: 24/7 Interventional Radiology services in all Major Trauma centres • National Survey • Visits to 24 Major Trauma Centres • Publication of Learning Document • 2 National Workshops to launch the document and share good practice
- 48. Aim: Provide access to IR services for all, 24/7 Focus on core procedures- embolisation for haemorrhage (general and PPH), endovascular intervention, nephrostomy • Promoting Networks • East Midlands and South West (Interviews and visits) • Other possible networks (telephone interviews) • Workshops East Midlands and Southwest • 3rd IR Survey 2013 IR work in 2013 IR work in 2013: access to IR
- 49. Red: No core service provision and no network pathways - includes adhoc rotas. Amber: Some core services available on a formal rota, limited formal network provision Green: Core service provision or partial service provision with a formal rota and formal network pathways to an agreed recipient trust. White : No data received NHS Improvement Survey 2011, MTCs
- 52. Total IR RAG status (as at 16/05/2012) 51.1% 44.8% 28.2% 26.9% 20.6% 28.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Survey 1 Survey 2
- 53. Staffing (Actuals) 0 50 100 150 200 250 300 350 North East North West Yorkshire and Humberside East Midlands West Midlands East of England London South East Coast South Central South West WTE Radiologists IR Radiologists Radiographers IR Nurses
- 54. Nephrostomy - Interventions per Radiologist 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 N orth East N orth W est Yorkshire and Hum berside EastM idlands W estM idlands EastofEngland LondonSouth EastCoast South C entral South W est #Interventions
- 55. Uterine Fibroid Emolization - Interventions per Radiologist 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 N orth East N orth W est Yorkshire and H um bersideEastM idlandsW estM idlandsEastofEngland LondonSouth EastCoast South C entral South W est #Interventions
- 56. Two key issues remain 1. Lack of network approaches 2. Lack of IR Radiologists
- 57. WEST HERTFORDSHIRE HOSPITALS NHS TRUST ROYAL BERKSHIRE NHS FOUNDATION TRUST OXFORD RADCLIFFE HOSPITALS NHS TRUST BUCKINGHAMSHIRE HEALTHCARE NHS TRUST MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS FOUNDATION TRUST NUFFIELD ORTHOPAEDIC CENTRE NHS TRUST BEDFORD HOSPITAL NHS TRUST LUTON AND DUNSTABLE HOSPITAL NHS FOUNDATION TRUST IR Consultant IR Radiographers IR Nurses Nuffield 4 4 7 H Wood & W Pk 5 5 2 W Hearts 2 6 4 R Berks 4 4 9 Bucks health 2 8 3 Bedford 1 5 4 Luton 2 7 2 Oxford 6 7 10 M Keynes 2 2 2 Total 28 48 44
- 58. WESTON AREA HEALTH NHST NORTH BRISTOL NHS TRUST UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST WYE VALLEY NHS TRUST SOUTH WARWICKSHIRE UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST ROYAL UNITED HOSPITAL BATH NHS TRUST GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST IR Consultants/Consultant Radiologists IR Radiographers IR Nurses RUH Bath 3/16 5 4 UH Bristol 7/29 4 3 Gloucester 3/12 4 6 S Warwickshire 4/9 0 0 Great Western Hospitals 3/11 5 4 Worcester 3/14 8 3 Wye Valley 1/8 3 1 Coventry and Warwick 4/25 3 8 North Bristol 6/24 6 12 Weston Area Health 1/6 1 0 Total 35/154 39 41 South West
- 59. • Interventional Radiology • On site Yes 84 64% No 48 36%
- 60. Endoscopy: what looks good? • An accredited endoscopy service that participates in • Global Rating System (GRS) • National audit • 24/7 service for GI bleeding, networked or in-house • Access to flexi-sig or colonoscopy in <4 wks for all patients >40 with recent onset rectal bleeding and/or persistent (>3 weeks) diarrhoea. • Compliant with NICE standards NHS England
- 62. ‘‘Hospital services should be commissioned to provide: 24 hr 7 day endoscopy service for GI bleeding’’ ‘‘Average GI bleeding mortality rate = 10% is ↓ by access to 24/7 endoscopy, IR & surgery as an MDT’’ GI bleeding toolkit: http://aomrc.org.uk/projects/upper-gastrointestinal-bleeding-toolkit.html
- 63. • 132 of 156 85% responded • Self reported RAG status of OOH AUGIB service Green 81 61% Amber 32 24% Red 19 14% Survey of acute service providers
- 64. • NICE Quality Standard 2 – Timing of endoscopy (immediate for haemodynamically unstable) Yes 100 76% No 32 24%
- 65. • NICE quality standard 3 – People with AUGIB who are haemodynamically stable are offered endoscopy within 24 hrs of admission Yes 72 55% No 60 45%
- 66. • Interventional Radiology • On site Yes 84 64% No 48 36%
- 67. NHS | Presentation to [XXXX Company] | [Type Date]67 • Network Yes 61 46% No 71 54%
- 68. • Barriers currently or envisaged to providing 24/7 therapeutic endoscopy
- 69. • Rota’s
- 71. Open 24 hours?
- 72. Why the variation across the week? Patients at weekends • Fewer discharges to alternative place of rehab or death • People wait longer before seeking help, admission thresholds raised Staff at weekends • Fewer • Less experienced • More exhausted Available services • Diagnostics • Specialist interventions • Discharge support
- 73. 24/7 Extended Day +/- 7/7 Diagnostics Tertiary Care In Patient A&E Stroke Strategy Primary Care Increased Access Patient Choice Secondary Care delivery – Out Patient Specialist Care Service delivery model
- 74. Anaesthesia Monitoring VentilationECG Echo/Contrast CatheterScan one cardiac patient . . . 10-day hospital stay . . . …….six departments . . . 105 healthcare professionals Hidden diagnostic services
- 77. “Be ambitious – you can’t take two steps over a gap” David Lloyd George