Summary of Discussions

The requirement from patients

This must be about delivering a quality patient experience as well as a shorter patient journey. Patients want a service that sees them as an individual - not a number in a system. If they are treated as individuals they may well need varying amounts of time to come to terms with a diagnosis and think about treatment options - 18 weeks gives four months, and if the whole pathway is speeded up it should be possible to give the space where it's needed by the patient.

Patients need emotional support as well as clinical treatment. That doesn't just mean when in face to face encounters with staff. It also means being treated with dignity and respect when in the pathway ie :

• being seen on time when they have an appointment
• being able to arrange appointments that are convenient
• having some control over the whole process
• being able to park easily near to where they have been asked to attend (and not being charged to do it)
• being able to bring someone for comfort if they wish
• not having to wait (a month) for our convenience to get results they might be worried about that could be available and given immediately.

These quality measures of a service from a patient perspective might seem like cloud cuckoo land - but actually they're pretty reasonable. So we should be also measuring the quality of the whole experience in addition to the overall time it takes. And as for the time, 18 weeks is actually a really long time when you're waiting for a diagnosis and you're in a lot of discomfort and you need some treatment now, please.

Are any patients involved in the operational planning for roll-out ? Not just as a focus group or patient involvement event either but patients sitting at the table as equals. If not, why not?

Patient choice, and how quickly patients want to be treated: recent discussions with low vision and audiology patients they said they wanted more time to make adjustments, i.e. grieving time to come to terms with illness / disability before treatment.

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The challenges to health systems

Scale and scope of challenge, transformational change and awareness

• The delivery of the target requires a step change in improvement and collaboration across all organisations.
• There is a lack of awareness of the scale and scope of the challenges, and the serious implications for all NHS organisations and teams.
• The required transformational change cannot be secured by central prescription; it will be inhibited by too much audit and lack of flexibilities, risking system failures.

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Changing behaviours and mindsets

• Wide agreement that 18 weeks simply cannot be met by working harder / faster
• Smarter working requires new kinds of relationship and behaviours between organisations providing services along the pathway, at operational and leadership levels
• Respect for patients and flexibility in meeting their needs also needs to be developed across the whole system
• All this needs to happen in a new environment in which the contestability and organisational change are placing pressure on collaboration

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Robust frameworks for local collaboration are required, with explicit programme management.

• Patient involvement is needed throughout the planning and roll out
• ISIP can be the vehicle for this
• Is there a need for a dedicated and funded pan LHC programme team. Should at least be overarching programme manager. ?
• Once principles are established, a whole system modelling exercise with wide participation is needed to test what if scenarios and cement engagement.
• Shared ownership of waiting lists and true management of demand are seen as key to progressing towards target. However target can only be achieved by collaboration across all commissioners and providers at precisely the time when contestability and choice will be producing counter pressures.

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Some long lead time processes need to be initiated now

• Development of PBC and new commissioning competencies and systems for case management (focus on the patient) and performance management (focus on the target)
• Development of collaborative and patient centred behaviours by clinical staff , managers and leaders in a new environment in which both collaboration and competition co-exist
• Development of integrated pathways across the Local Health Community to minimise variation in system.
• Development of robust information systems (see below)
• Finding the clinical capacity, resources and health community ownership to clear current backlogs.

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Major challenges for commissioners in management along the pathway

• The PCT bears the responsibility, if a breach occurs. How do they secure compliance ?
• Plurality of providers and multiple hand-offs risk breaches and patient safety
• Concern expressed over clinical risk associated with “loss” of patients across system.  Needs clear accountability over who is clinically responsible for patient at each stage of pathway.
• Case management arrangements would need to be operate efficiently alongside social care case management
• However, care needs to be taken to avoid creating a system which only commissions mediocre services / pathways – need to be able to respond exceptionally to exceptional cases
• The later providers in the chain lose if an earlier provider fails to deliver on time.  If the PCT spot commissions the final stages from elsewhere in order to avoid a breach, the secondary or tertiary treatment provider will lose on bread and butter services on the pathway, or the commissioner pays twice to get one service
• PCTs / PBCs may also face loss where patients exercise choice of treatment with out-of-area providers over whom they have little or no commissioning leverage.
• Commissioners will need to undertake much more sophisticated contingency planning to assure continuing provision along chains that will deliver treatment within 18 weeks. Referrers, and referral managers will need real time forecasts of turn-round times for intermediate stages future delivery.
• Secondary care providers lose their established in house capacity to monitor and manage potential breaches.
• Unknown capacity and capabilities of new PCTs and PBC for sophisticated management of contracts, risks and relationships with providers
• Difficulty of putting forward practical arrangements until the practical detail of new PBC /PCT Commissioning and Choice are clearer.

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Information systems and the competencies to use them.

• For the purposes of case, contract and performance management, information needs to move quickly, and reliably across the boundaries of NHS, IS and social care organisations.
• The way forward was seen as focussing on enabling the free movement / translation of data, rather than the integration of systems.
• This would require changes in attitudes to the collection and use of data
• Reporting from information systems should also present patients and carers with a user-friendly way of understanding what lies ahead of them along their unfolding pathway.

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Downloads

• Zipfile of all downloads available on this page
• Summary of Discussions as a Word document
• Diagnostics  Presentation | Write up
• Patients Presentation |  Notes
• Whole System  Write-up
• Performance Presentation |  Write up
• About this event
• WYSHA Submission of Key points with a West Yorkshire concensus available shortly

18 weeks website  | Principles & Definitions    

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