The role of human resources and admin teams in getting NHS waiting lists down to size deserves recognition, says Andy Cowper
Sometimes, it is about symmetry. The 18-week figure chosen by the government as the target maximum time from GP referral to treatment was no doubt picked to represent a quantum leap from the 18-month waits that were common when New Labour swept to power over a decade ago.
Health secretary Alan Johnson recently released figures showing that more than 90 per cent of trusts were already hitting the 18-week target. Achieving this has been a great team effort, but the human resources community's contribution has not been recognised. From the outset, it was clear that as well as systematic measurement of patient journey times and improved management of operating lists, changing workforce roles would be essential to ensure success.
Many ways to enable change in job roles and to increase staff skills and flexibility go back to HR in the NHS Plan, which was published in 2000. This introduced the new Agenda For Change pay deals and the skills escalator.
The efficiency challenges facing the public sector have driven workforce change, but bigger contributions to the HR community's impact on 18 weeks have been the elements of new skills, new job roles and flexible working made possible by the long term HR strategy on which the NHS has since built.
Supply of staff has also been a significant consideration. The health service has enjoyed real terms and above inflation budget growth in every financial year since 2000. Until the deficits emerged in 2005-06, this enabled expansion to cover a certain amount of the challenge. But in financial recovery, this was not sustainable.
Maxine Foster, the Department of Health's 18 weeks workforce development lead, says the health service is on track for the target, thanks to "a lot of people working extremely hard". However, she cautions that it is not just about working harder, it is about working smarter too, and that "now it needs to be the other way round".
She is clear that to sustain progress, with tighter economic times on the immediate horizon, "really focusing every care pathway on 18 weeks and encouraging more efficient commissioning" is vital.
In care pathway redesign, she says that "focusing on the 'pinch points' where there may seem to be a lack of people" has been instrumental to success - but that the solutions are about redesigning roles and improving staff skill-mix to extend workforce capacity.
She cites the example of medical secretaries who now have active roles in waiting list management. She also observes that many organisations have used pathway redesign to eliminate unnecessary activities and duplications and to reduce multiple handovers and tests.
She highlights the 18 weeks team's work with NHS Employers, to spread messages about HR's "need to engage with service managers struggling to keep waiting lists down".
"My message to managers is to go to your HR team and ask them for help," she explains. "It's not just a conversation about filling vacancies, it's about workforce redesign and transformational change to sustain 18 weeks."
She adds that HR needs to plan for more provision in the community: "Our events looked at aspects of moving care into the community, and whether there's the education, capacity for training and supervision in primary care to allow a safe move of services from hospitals to the community.
"We're following this through Skills for Health, who've helped collect numerous examples of hospital roles moved into primary care. Our focus now is on potential educational support for national spread and roll-out with these service changes, rather than in pockets of early innovation".
She observes that peer support may become harder to facilitate, as care moves outside hospitals that enjoy established training and development infrastructure.
Ms Foster stresses the need "to plan your workforce for next year and beyond 18 weeks - next August is the European working time directive deadline, bringing additional pressures to trusts still struggling to reduce junior doctors' hours.
"With that and maintaining 18 weeks, it might be very challenging for some. You need to have an integrated plan for both issues: don't regard them as separate."
For anyone who might feel a little overwhelmed by all this information and need guidance on how to focus on 18 weeks, there is a series of workforce planning masterclasses for HR practitioners on the workforce pages of the 18 weeks website and Skills for Health's (details below).
Some trusts have introduced roles that track patient progress and resolve delays. NHS Yorkshire and the Humber has established an 18 weeks admin project, using admin staff to smooth patient pathways.
Philip Shields, consultant project manager for the strategic health authority, confirms that many trusts identified admin as a sticking point on their elective care pathways, and that after a concerted effort across the patch, the admin support changes are bedding in. He echoes Maxine Foster's message about the need to sustain the effort, noting the recent rise in acute referrals. He thinks the greater involvement of admin staff in 18 weeks management and the evolution of their roles to track patient progress, highlight delays and seek to resolve them result from a change in attitude within trusts, as they try to see the care process from the patient's viewpoint. He emphasises practical and simple tools, such as text message reminders about appointments or about phoning for test results, as well as new software to help medical secretaries to track the patient's progress through the 18-week journey.
His advice is: "Don't neglect your admin staff - it's about having some leadership for admin as a serious professional group and looking after their career development and training. Without good admin support, the whole thing falls down".
Judy Moorhouse, Calderdale and Huddersfield foundation trust assistant director of surgery and anaesthetics, outlines how her trust has introduced patient trackers by volume of work. "We have three trackers in our division at the moment whose main focus is tracking patients across the 18-week pathway, considering patients' and carers' experience," she explains.
These trackers will talk to patients who may choose to hold up their own journey time: "Many simply don't expect to be offered a date in the near future!"
Trackers liaise with staff, from outpatients to consultants and theatre staff, to discuss when extra theatre time may be needed if patients are running out of journey time. Ms Moorhouse says trackers "have been very useful helping us understand some issues on patient pathways. As part of our 18 weeks sustainability work, we've been reordering patient pathways, looking at handoffs and gaps, then working with PCT colleagues to reorder pathways to deliver within 18 weeks. Trackers help us identify bottlenecks and their implications."
The trust also uses people in another new role: service improvement facilitators, who work closely with divisional managers, to look at care pathways with clinicians and decide how to reorder pathways by working with clinical teams.'
Ms Moorhouse says admin trackers and facilitators need to work with clinical colleagues to ensure changes are appropriate. The trust has created various one-stop shops to minimise test and outpatient appointments - which, as she says, "from a patient experience point of view, is a big improvement".
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