A Mantra to take with us into 2021

 

As 2020 draws to a close, and the majority of us find ourselves in another lockdown, it takes some doing to reflect on the year we have had. ‘Unprecedented’ has become trite in our ‘year like no other’. But when the impact of Covid was first felt, way back in March – who would have expected we would be here at Christmas?

 

We all know the challenges the NHS, the country and indeed the whole world have gone through this year. So, rather than dwell on those, I would like to focus instead on what we have learnt and can take forward into the new year.

 

Early in the year, many at the helm of some organisations worried whether employees could be industrious at home and not be distracted by the glimmering lights of Netflix or the chance to improve their green fingers. They need not have feared as studies have instead proven that productivity increased during this time. Perhaps the structure of work provided a level of certainty which was needed during this uncertain time. Sure enough, soon all organisations found that placing trust in their employees only helped give their staff a sense of purpose with autonomy. Something maybe some of us had not seen the likes of before this unparalleled time thrust it upon us.

 

Trust was a theme throughout in defining our response to the pandemic – whether that was the NHS trusting new innovations and embarking fearlessly on its digital journey, or the pharmaceutical industries who globally trusted each other and worked together to deliver us the much needed and valued vaccines. Trusting each other got us there. It made us resilient against the challenge at hand.

 

We, at Acumentice, have also learnt from the trials presented by this year. We adapted our strategy and adopted differing working methods both internally as well with our NHS partners.

 

Our focus this year has been to support Integrated Care Systems find their feet in supporting restoration and becoming more resilient by trusting their partner organisations. This has led to some of the most amazing innovations I have seen in my time within the NHS and it feels incredible to be part of such journeys of discovery.

 

Our focus next year will be to maintain this reignited strength in collaboration, to build on the trust in our teams and partner organisations, to take stock of how adaptable we have proven ourselves to be when needs must and to start the year with a sense of confidence, resilience, and hope.

 

I wish everyone a happy and safe Christmas and a much brighter new year!

 

 

Karina Malhotra

Founder and Managing Director at Acumentice

Those who regularly read our news posts and follow us on Twitter and LinkedIn will know that we recently exhibited at the fantastic NHS Providers Annual Conference and Exhibition 2020. Taking place across three days, we are immensely proud for this to have been our first exhibition and conference. However, this was not the only first. It was also the first time NHS Providers hosted the event virtually – something we can now expect to see happen increasingly for the foreseeable future. It was, therefore, excellent to see high levels of engagement which we are certain had a lot to do with the impressive line-up of several high-profile keynote speakers and thought-provoking sessions.
As we are entering what is now generally agreed to be a second wave of COVID-19, this event could not have been more timely.
With over 900 attendees and 85 speakers, it was certainly a busy 3 days. Our senior consultants were on hand to speak with visitors to our virtual stand and we managed to balance this with attending many of the speeches and sessions too. With the conference’s theme, ‘reflect and recover’, it will not be surprising to learn that there was much reflection on the huge efforts made by all those working for the NHS, in all capacities, not only during the first wave of the pandemic earlier this year, but the continuing efforts and what likely lies ahead in the coming months. In a keynote address, Rt Hon health secretary Matt Hancock offered his thanks, “Everyone who works in the NHS knows how valued they are by the public, and by me…”. In a change of tone to how the first wave was handled, he also underlined the importance of maintaining, wherever possible, non-covid services over the winter period.
Diversity was also a dominant theme, not only on efforts to diversify the current workforce in the NHS, but also addressing the unequal impact of COVID-19 on those who identify as BAME. What can be done moving forward, as we increasingly find ourselves entering a second wave, to prevent the BAME community being disproportionately affected? We found the New York Times bestselling author, John Amaechi to be particularly inspiring, “The enemy of inclusion is not what you think… it is mediocrity. When you open up an opportunity to a wider number of people, mediocrity is exposed.” In addition, Patricia Miller OBE, Chief Executive of Dorset County Hospital NHS Foundation Trust, infused us with her passion on addressing issues of diversity and inclusivity from a Trust Board perspective.
Digital transformation featured heavily too. Digital plans that were in the pipeline pre-COVID and scheduled to happen in the next 3-5 years, have out of necessity taken place in 2020, due in large part to the meet the pressures of COVID-19. Many appointments are now taking place virtually, and this is likely to continue for the foreseeable future. In addition, as many of us continue to work remotely, software’s such as Microsoft Teams, have played a massive part in enabling communication to continue successfully.
The theme of COVID-19 stimulating accelerated change also featured in one discussion we found particularly enlightening, Step-up to day case: Attacking waiting lists to support the recovery – two transformative examples. Two speakers, Eric Mutema, Consultant Obstetrician and Gynaecologist, Blackpool Victoria Hospital, and Sean Carrie, Consultant ENT Surgeon and Rhinologist, Freeman Hospital and University of Newcastle upon Tyne, brilliantly showcased how they have successfully reduced the demands on the NHS for inpatient care, not only making savings for the NHS but also enabling better patient care and safety. It was great to see some positive news in a year which has brought hard challenges for many.
Overall, it was a great event and good news too that all sessions remain available to access online for another three months. We are looking forward to next year’s event and have the dates in our diaries already!

The Phase 3 letter at the end of July issued a clear direction of travel in relation to the management of elective waiting lists at system level.  It placed an emphasis on ensuring equality of access for patients and an effective use of resources across the system footprint. This was further backed up in the following weeks with the confirmation that both activity baselines and funding envelopes would be determined and awarded on a system level.

 

Whilst some systems were beginning to explore how system level waiting lists would be developed practically ahead of the pandemic, the detail surrounding how to achieve this was probably best considered as emerging.  Now systems face the challenge of delivering the requirement at pace along with some of the most ambitious recovery planning that they are likely to have ever undertaken.

 

The challenges to developing and embedding the requirements can be set into three broad categories: technological, operational processes and oversight & success criteria.  Beyond this are a number of more existential issues with what the policy position implies, particularly regarding how to identify and utilise genuine excess capacity and how to manage messaging to, and expectations of, patients regarding moving between different providers.

 

Solving the technological challenge

 

The task of merging the waiting lists of distinct providers is potentially the most straightforward of the challenges if the right technological solution is implemented but certainly the factor which will cause most damage to a system’s efforts if the reverse is true. There are different options available which range from provider Trusts sharing the same incidence of a PAS/EPR to implementing a third-party tool which aggregates the various data and provides a ‘virtual’ merged PTL.  In reality, there are few systems which have to date wanted or needed to ensure a common platform between providers and therefore it is likely that some method of extracting and combining waiting list data will be required.

 

Inevitably different systems will employ different approaches, and this is not necessarily a bad thing provided that there are consistent standards and deliverables across the different methods.  First amongst these clearly is that the approach is safe; the potential for groups of or individual patients to be overlooked, inappropriately deprioritised, or simply lost is very real. Unfortunately, this risk has been realised consistently when providers alter their own system architecture even at a single site level and with comparatively generous timescales and pressures than we see now.  Similarly important is that the approach is practically manageable; duplication or double entry and multiple versions of the same data will signal the rapid end for engagement with the process.

 

At Acumentice, we have previously led the implementation of a digital patient management system (Qubit Health) at Imperial Healthcare NHS Trust which offers a PAS agnostic aggregation of PTLs.  This approach has been extremely successful in creating efficiencies in managing several PTLs across this large and complex organisation.  Recognising the current need, we have been working with our associates at Qubit Health on further enhancing this system to support, among its various features, the aggregation and management of a shared PTL across a system.

 

Operational and process challenges

 

Alongside the job of getting all the information in one place is the project of developing a set of standard operating procedures which allow a diverse set of teams to continue the myriad tasks associated with managing it.  Booking and scheduling of patients takes on a very different flavour when it is done at system level and at a significant extra level of complexity if we assume that it remains a task carried out by local teams at each site.  Whilst centralising booking and scheduling at system level would be an option, the reality is that this will unlikely be a route taken in the short term.

 

As well as ensuring the process supports teams working on a single PTL collaboratively, systems will need to fix and communicate any changes to scheduling priorities from the outset to ensure a consistent approach is taken.  Where a technological solution does not provide an immediately updated waiting list position, the success of the logistics and communication of booking progress will be pivotal.  Many areas will have experience of outsourcing to the independent sector and associated memories of complex and time-consuming administration; clearly, a bad outcome would be any system that replicated some of these intricacies on a bigger scale.  Fortunately, outsourcing has played a big part in the previous phases of the NHS response to COVID-19 and the opportunities for smoothing out processes which will form part of this, as well as the continued use of the independent sector, have been plentiful.

 

Determining success

 

In the absence of the headline measure of performance being applied in a meaningful way, success for elective care in the next few months will be solely determined by the activity targets set out by the phase 3 letter.  Many of the indirect measures that organisations have previously used as part of a sensible suite of success indicators will still be relevant, if in need of a mild reimagining.  Efficiency and maximising use of capacity is naturally going to be important, however some of the existing assumptions as to what is achievable will need remodelling to reflect the entire system’s capacity.

 

A reduction in the overall system PTL size, and the corresponding reduction in long waiting cohorts, would also be considered good outcomes, however this would need to form part of a compound measure which also protected against pockets of inequity developing in certain services or certain parts of the system.  Importantly, as assessments are made by clinicians in each system, what is considered inequitable and what is considered an unfortunate but otherwise relatively safe consequence of the circumstances remains to be seen.

 

Ultimately, facilitating individual Trusts’ access to additional capacity and wider support across the system is a welcome step.  Assuming the capacity itself can be released, a successful implementation of a system level waiting list will increase the likelihood that priority patients will be seen more quickly and serve to reduce risk.  It also comes at a time when it provides a further incentive to system leadership teams to build on their collaborative working and to capitalise on the positive moves in that direction that this year has brought about.

Philip Purdy

Senior consultant with Acumentice

Arriving at the end of July, the letter to systems setting out the third phase of the NHS response to Covid-19 was the first time expectations for recovery and restoration were prescribed. Significant and rapid acceleration of non-Covid activity over the course of the next three months made up a major part of these priorities.

 

The phase 3 letter sets out the expectation that trusts and systems should deliver at least 80% of their previous year’s activity for both overnight electives and for outpatient/day case procedures in September, rising to 90% in October and aiming for 70% in August. It goes on to recognise that this requires a return to at least 90% of the previous year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100% by October. Finally, there is a need to reach 100% of the previous year’s activity for first outpatient attendances and follow-ups from September and through the balance of the year. Based on the latest national figures (June 2020 HES, specific acute) there is a significant gap to make up to achieve the target milestones, with day case and ordinary admissions both sitting in June at around 45% of September 2019 levels and first outpatient attendance and subsequent outpatient attendance at around 62% and 72% respectively.

 

As they stand, the current expectations are not set in terms of either a target RTT performance percentage or waiting list size, but in terms of plain activity. The removal of the complexity of planning to achieve a performance standard and/or waiting list size target in this phase of the NHS’s recovery is a good thing, activity is the easiest unit of measurement to work with. This represents a shift away from previous recovery drives and perhaps demonstrates a very necessary injection of pragmatism considering the scale of the challenge. That said, within the detail of the planning returns, there is an expectation to provide total RTT waiting list figures and over 52 week waiter numbers on a monthly basis. So, when planning, it will still be important to isolate clock stopping activity from other planned activity. This will need doing at quite a granular level when determining each set of actions required and their impact.

 

The pre-existing prioritisation principles for elective care remain unchanged, namely high clinical priority (urgents) first, followed by the longest waiters in RTT pathway chronological terms.  As a result, there are two different goals that need to be considered equally important throughout the planning phase and beyond: seeing and treating enough people (to meet 2019 levels) and seeing and treating the right people (to limit the growth of long waiters and ensure a clinically appropriate distribution). What each clinical service takes to understand as a clinical priority is of course an emerging concept in late summer 2020.

 

So where to start? Despite the 21^st September deadline for the submission of system plans, this will inevitably be an iterative process. Providers may wish to prioritise understanding where (in which specialties) these milestone activity targets are more and less achievable considering: the starting point (current levels of activity achieved throughout phase 2) and the nature and complexity of any extraordinary measures necessary to meet existing and required levels of activity – i.e. understand the barriers at an early stage. Those barriers may also be helpfully expressed in clear and consistent categories allowing for the task of meeting their various challenges to be distributed appropriately across different parts of the system: e.g. in terms of estate restraints, staffing, clinical pathway barriers etc.

 

There is a clear direction in the phase 3 letter to make use of alternative options for generating capacity, in some cases these efforts will aim to free up more traditional capacity options and in others to replace the face-to-face appointments which provide an ongoing risk to be managed in relation to the virus. Systems will want to work as a priority to develop local protocols and identify appropriate opportunities for increased use of advice and guidance routes to prevent onward referrals and ease the pressure as well as implementation of patient initiated follow-up (PIFU) and expansion of telephone/video OPAs in order to provide capacity release elsewhere in the service. On top of this, maintaining and going further on independent sector capacity utilisation from both an outsourcing and insourcing perspective will remain key.

 

Communication with patients will be paramount; there is clear expectation that those whose treatment has been affected by the pandemic are contacted and informed of next steps. This will take a significant coordination between primary and secondary care and establishing how to go about this will be another early priority. Providers may also wish to use the opportunity of contacting patients to review their clinical circumstances and implement different options for their onward pathway depending on the outcome.

 

One thing that is clear is that the need for accurate and accessible data will be essential at every turn. From understanding the detail of last year’s activity figures, to the ability and capacity to deliver those levels in the coming weeks; from effective clinical prioritisation to understanding the capability for outsourcing and alternative capacity options; and from identifying and reassuring those patients who have been delayed to the waiting list management techniques required to make a sustainable impact on an already fundamentally challenged sector of the NHS.

 

Thinking ahead, perhaps to “Phase 4”, the ask ahead of November for elective care is described as a ‘window of opportunity’ and so the assumption remains that there is a distinct possibility of a suspension of elective activity again over winter (this would be consistent with the last few winters irrespective of the pandemic). For now, success appears to be returning to pre-Covid levels of activity for a time, but two sizeable problems remain when we recall that September 2019 levels of activity were not sufficient to keep pace with demand twelve months ago. Firstly, how to make headway into the additional backlog caused by successive months of scaled back elective activity and secondly, how to meaningfully return to the task of taking a full and complete view of the scale of the problem for elective care performance, a task that was arguably overdue this time last year.

 

 

Philip Purdy

Senior consultant with Acumentice