Ingrid Torjesen

In the past, elective care waiting time targets focused on specific parts of the patient pathway – waits for outpatient appointment or operations – rather than the whole journey. This how the 18-week programme is different.

Patients have been followed and their whole journey mapped for the first time. By identifying blockages and delays the efficiency of existing services is being improved, and quality and value information is helping local health communities transform care pathways so patients experience a smoother and faster service.

Jenny Leonard, former head of transformation for the 18 week programme at the DH, says although all the evidence indicates that early sustainability planning results in long-term sustainability, this has rarely happened in the past. The solutions put in place were short term and not sustainable, as they often did not address underlying process problems.

“People put a lot of effort into delivery and they didn’t see the continued output of that effort,” she says. “It is about helping commissioners and communities to plan ahead and the NHS hasn’t been great at doing that.”

To clear huge historic backlogs, staff have worked tremendously hard, offering clinics into the evening and even at weekends.

“That type of work is not sustainable,” emphasises Mrs Leonard. “It was an interim quick solution. People were working long hours to maintain delivery of the target, preventing them from finding the time to review the service, consider alternatives, and really understand the demand and capacity of the service.

“Although it is difficult, people are now taking stock and investing a bit of time in coming up with alternative models or alternative solutions in terms of who, what, when and how, but also planning very differently.”

Ms Leonard also states that it is a challenge to transform services because it involves change across wider boundaries of organisations, staffing groups and budgets.

One of the biggest problems is that not many people know how to calculate capacity and demand for services, even though most recognise that it is important. Another is that relationships in some local health communities are “frayed” because of past financial challenges which need to be rebuilt, which is challenging in an environment where commissioning is evolving and the pace of change is rapid.

A lot of work is being done nationally to facilitate this and there are a variety of tools and support services for local health communities to draw on.

Working with the royal colleges and other associations the 18 Weeks programme drew up 42 commissioning pathways, such as knee pain and hip pain, for local health communities to use as a starting point for local discussion. These are based on existing good practice but also challenge the way things are done where necessary.

In terms of terminology this means talking about primary assessment, specialist assessment and super/supra specialist assessment rather than primary or secondary care, and what skills are required to undertake a role rather than the location where it takes place. It also means challenging where diagnostics take place to give primary care direct access where appropriate and ensuring results are shared along the pathway so diagnostics are not repeated.

The NHS Institute for Innovation and Improvement has developed the Sustainability Model to help organisations plan for sustainability (see box), while its No Delays Achiever uses information submitted by trusts and PCTs to help identify blocks and barriers and then pinpoints other useful tools.

But Ian Bayley, orthopaedic clinical adviser to the 18 weeks programme and a surgeon at the Royal National Orthopaedic Hospital in Stanmore, warns that tools and measurements are not enough.

“You can develop a tool but if the skills are not out there for people to take that tool up it never gets used,” he says. “If you deliver a tool you have to cascade it out into the service and we never did that previously.”

The 18 Weeks team has sought to remedy this through many sustainability sessions across the NHS, and now the Orthopaedics Coaching Programme has been developed to do this in orthopaedics using action learning methodology. It is based on experience from the National Orthopaedic Project - where the Ten High Impact Changes have their roots - and the National Clinical Leaders Programme, and targets not the most challenged organisations, which are helped by the intensive support team, but those just above, in the middle ground.

Each SHA has identified five or six such organisations to participate, bringing together people from across the whole health economy into a team supported by a DH representative, the SHA’s 18 Weeks lead and a senior orthopaedic clinician.

Mr Bayley says these clinicians include four former presidents of the British Orthopaedic Association. “This puts out the message to the local economy that the BOA is behind this, so sign up to it and get involved.”

“The teams set their own ground rules, which have proved hugely powerful because you can get people talking across the disciplines and that is when you start to make real progress,” he says.

“We are using the coaching programme for sustainability and if we stop the coaching programme now those organisations that we have worked with will go back to their old ways of working. We’ve seen that time and time again.”

He adds: “The difficulty is actually embedding the process into everyday working life. Pathway redesign should be part of the day job on an ongoing basis.”

Nationally the 18 weeks programme is looking at how developments in workforce and technology can be used to improve the pathways. With technology this involves horizon scanning to see where in future steps could be removed, added, enhanced or provided differently. With workforce it is about plugging gaps and ensuring sustainability.

Ms Leonard says: “Where sites are really transforming their pathways and looking at how they are working there is a real need for us to share this learning and seek opportunities for developing nationally transferable roles.

“That does not necessarily mean new roles, but could also include the education and training of GPs if we are going to move equipment to primary care and enable them to do more assessments and treatments.”

With more patients being managed in primary care, there is also a need to consider the role of self care with the help of NHS Choices, NHS Direct and pharmacy to help prevent patients from needing primary care support.

“The next stage is for commissioners to think about is how do they commission those sorts of services to prevent patients needing to even commence an 18 Weeks pathway in the first place,” she says.

Commissioners also need be looking into the future and commissioning services based on the future demographics of their population and engaging clinicians to shape services. But, she notes, world class commissioning will help drive this forward, but it is not enough on its own.

“It’s now about finding the solutions locally and having the time to implement them successfully. One solution doesn’t fit all. There is a real need to put into place transformed services to ensure sustainability of maximum 18 week pathways.”

(Box) The sustainability model

Lynne Maher head of innovation practice at the NHS Institute for Improvement and Innovation and author of the sustainability model emphasises that teams must plan for sustainability right from the outset of change programmes.

The sustainability model was born from the Modernisation Agency’s national booking programme, which Ms Maher used to be in charge of. She commissioned Birmingham University researchers to evaluate whether gains made by pilot organisations had been maintained. They found:

  • One third had either enhanced the improvement or spread the change to another department or organisation
  • One third had sustained the improvement
  • One third had gone back virtually to their old ways of working

Organisations that had sustained the change were compared with those that hadn’t to see what they were doing differently. The themes identified were pared down to ten key factors and these were weighted. The factors fell into three groups – staff, organisation and process.

“What we wanted to do was to develop something that people could use to assess how well they were setting their projects up for sustainability and then be able to do something about it, if assessment showed they weren’t doing very well,” Ms Maher says.

Initial feedback showed the tool helped identify problems but that people then did not know what to do about them. So the Institute developed a guide aligned to each factor to help with this.

Typically sustainability is something that is considered at the end of a project, but Ms Maher warns: “Actually it is too late, as it is difficult to change things right at the end of the project.”

Ideally the model should be used at the beginning of a project, in the middle and around three months before the end.

“Things change through the project life cycle and if you pick something up three months before the end at least you have got some time to sort it out,” she explains.

At the beginning of a project the overall score could be low because some factors will not be applicable. However, others, such as senior leadership (managerial) and clinical leadership (engagement) need to be there right from the start.

“If you have not got really good supportive managerial and senior clinical leader engagement you have a risk there really,” Ms Maher says.

“If they are not there throughout there is nothing you are going to be able to suddenly do towards the end.”

She also recommends that every member of the core team scores the model – and not just the project manager - because it helps bring out different perceptions and start useful conversations.

The model is currently being used in the UK, Canada, Australia and New Zealand and has been translated into Danish and Swedish. Kaiser Permanente in the US issue it as a core part of their improvement advisor training. A web-based version is in final testing.