Published: 03/11/2005 Volume 115 No. 5980 Page 24 25 26
With waits hitting three years in some areas, physiological measurement capacity is stretched to breaking point.
Alison Moore looks at strategies to ease the pressure
Mention diagnostic services to many chief executives and they will talk about the improvements they are making in radiology services, the shorter waits for scans and, at a pinch, they may throw in endoscopy or pathology.
But while they are extolling the virtues of the new£1m scanner, the longest waits in their organisations - and the biggest challenge in meeting the 18-week waiting target - may be in the field of physiological measurement (PM).
This hotchpotch of services covers everything from vascular to sleep monitoring, alongside respiratory services, urodynamics, hearing tests and heart monitoring. Put together, there are 10 million procedures a year - but this total is made up of about 100 separate tests. A number are low cost, high volume, and many trusts will have extensive teams involved in them. But others are less common and more complex - and may be dependent on just one member of staff.
'They are backroom boys working in the cellars of the hospital, ' says Gilbert Wieringa, diagnostics lead for Greater Manchester strategic health authority. 'Low awareness has translated into low investment but it will really bite people in the bottom when it comes to the 18-week target.
There is a huge gap between the capacity required and the capacity on the ground.' To get to 18 weeks, many managers believe waits of no more than three weeks in diagnostics, including PM, will be needed; yet some SHA areas are understood to have waits of three years for services.
Professor Sue Hill, Department of Health chief scientific officer and national clinical lead for PM, is chairing a leadership group set up to look at the area. This is developing a programme to identify bottlenecks that could impact on the 18-week target.
A service framework is also being developed.
From the New Year, trusts will need to file details of waits in seven areas to the Department of Health. Professor Hill says it is important to understand the position, including the wait for different components of the journey through all of the PM services - especially as some, such as audiology, involve both diagnostic and therapeutic services.
So what are the problems? The first is simply that it is hard to get a handle on what is going on where. Lack of data and a low priority mean the issues affecting PM simply do not get on boards' agendas. For many areas, a mapping exercise is the first step to solving the problems, and meeting the interim target of no waits for diagnostics longer than 13 weeks by March 2007.
Areas which have carried this out have found there is very little use of IT, with much data still being retrieved from paper-based systems - which may make filing returns from January difficult. In some cases, managers who have successfully redesigned other services in their remit had never thought to use the same tools with PM. 'A lot of the services seem not to have been measured and it is classic to only manage what you can measure, ' says Jane French, diagnostics delivery manager with Leicestershire, Rutland and Northamptonshire SHA.
Trusts in her area have now agreed a target of no waits for diagnostics of more than four weeks by December 2007. 'The one thing they have discovered is how little they know, ' she says.
'What one trust classes as a PM test, another may put in a different category because of the way they configure their services. There is little uniformity.' The service has not only got to hit 18 weeks, she points out, but also a raft of other targets, such as cancer waits, which should not be forgotten. Nationally, the services which have done most to reform themselves seem to be those which link into national priorities or service frameworks, such as coronary heart disease.
Kevin Wyke, who is leading on PM for the Greater Manchester PCTs, says solutions have to deliver 'good quality sustainable services' as well as hitting the 18-week target.
So much from so few Some areas will struggle to find the capacity to eliminate long waits, especially if the service is dependent on a small number of individuals.
Demands for some tests - such as those used in heart failure - is increasing, points out Royal College of Physicians president Professor Carol Black, who is working with Professor Hill on PM.
Moving some work out of NHS secondary care into the community is one option - and has already happened with some services. In Greater Manchester, a scheme to deliver tests to patients through a 'diagnostic ambulance' is in its early stage and could include some PM tests. Many tests which would have required a hospital visit are now provided in GPs' surgeries.
'It is imperative that pathways involving the use of PM diagnostics are developed in conjunction with the primary and secondary sectors and all the relevant members of the delivery team, ' says Professor Hill.
But there are concerns about the quality of interpretation in some cases (eg electrocardiograms) and this can lead to duplication, with hospital doctors asking for repeat tests because they are uncertain about the quality. Training, and working to protocols and agreed standards, can help, as well as defining service pathways and effective patient selection.
Direct referral by GPs - either to diagnostic services or onwards on the basis of tests the GP has done themselves - can also cut waiting times, but there are concerns about managing demand.
In some cases, ECGs used as the basis of GP referrals are screened by consultants or senior technicians to check they are appropriate.
And in some cases the tests can be provided in the community, closer to patients' homes. But the workforce has to come from hospital services, which is unlikely to increase capacity.
Buying excess capacity from the independent sector can offer another solution. Some PM work, such as ECGs, is included in the second wave of diagnostics procurement. But some of the rarer tests are hard to source in the independent sector.
Echocardiography, where it is not feasible for trusts to train staff up for the 2008 deadline (training takes four years), may benefit from independent sector involvement. But the workforce shortages that affect the NHS in some of these specialised areas often affect the independent sector as well.
Developing extended roles and skill mix is seen as one way forward. But there are limits to what it can achieve. Cheshire and Merseyside SHA diagnostics lead Marisa Logan says: 'We can extend roles but there are cut-off points where you need a clinical physiologist.' Often the picture is muddled by lack of planning. For example, there may be people in training but no funding for the jobs they would occupy once they complete this. Workforce development is patchy, especially in some of the smaller services.
And because much of the work done in this area is low profile - often not dealing with the emotive, life-threatening diseases - there is little public knowledge of what clinicians and technicians in these areas do. This may affect recruitment.
High-level sign-up to changes is necessary, but in the SHA areas with good information and plans for change this has been achieved.
Leicestershire, Rutland and Northamptonshire has a diagnostics board with chief executive or director of operations representation, for example. The board reports to the chief executives' forum.
In West Yorkshire, the diagnostics team is trying to pinpoint long waits and help trusts improve their care pathways. But SHA diagnostics lead Dawn Stephenson says areas of good practice are being uncovered as well.
The challenge for all SHAs will be ensuring the lessons of those pockets of good practice are then spread across all PM tests. .
UNIVERSITY HOSPITALS OF LEICESTER
STREAMLINING THE PATHWAY
When patients are referred to cardiologists at University Hospitals of Leicester trust, they are likely to be called in for tests before their outpatient appointment.
That means that by the time they see a consultant much more is known about them and the consultant can discuss treatment options earlier. Some patients may not even need to see a doctor.
There are considerable savings in doctors' time - they will see patients once, rather than twice, or not at all. Waiting times to treatment are obviously reduced.
It is a simple system which the unit has run for several years for tests such as echocardiography, exercise tolerance and 24-hour ECGs. Service manager Sue McLeod says: 'I was shocked to learn that it was not done elsewhere.' Last year the trust was able to offer tests very quickly - for example, echocardiography within one to two weeks.
But this year waiting times have started to creep up. The trust has some unfilled vacancies for cardiophysiologists, where there are national shortages.
Payment by results may also affect the service's financial viability. The trust is trying to clarify whether it will be paid for both a test and an outpatient visit when patients are given early tests. The Department of Health confirmed that it is being considered at national level.
CHESHIRE AND MERSEYSIDE
KNOW YOUR STARTING POINT
'We may have several hundred people waiting up to 70 weeks for tests, but we need to know whether these are real waits or the results of less-than-robust data, ' says Cheshire and Merseyside strategic health authority diagnostics lead Marisa Logan, who has just coordinated a mapping study of the physiological measurement services in the area.
Cheshire and Merseyside is now ahead of the pack, having a good idea of what is provided where, how long patients have to wait (although some of the data on this needs re-verifying) and workforce structure.
The picture which emerges is complex, but some key issues came out of the exercise:
There are long waits for some procedures - both high-volume, lowcost procedures and some less common ones.
There are capacity issues for some procedures, with an increasing number of referrals making reducing waits difficult, with 'steady increases' in some areas.
Some services involved staff members working alone. In vascular and gastrointestinal services, for example, 'if two members of staff went off sick the service would have to stop'.
Some posts are vacant and there is little workforce planning, let alone succession planning for an ageing workforce. There are no vascular trainees, for example.
Based on current data, five services - spirometry, pure tone audiometry, electromyography, echocardiography and electrocardiography - are identified as risks to the 18-week target.
The SHA is now developing a PM strategy, including:
Network groups for each specialty.
Trusts to appoint a PM lead to raise the profile of the services.
More co-ordination of training and workforce across the SHA.
Funding mechanisms which reward and recognise PM activity.
Encouraging trusts to look at what workforce they need and ensuring that PM is planned into any changes in work.
Ms Logan says the SHA may be further advanced in analysing the problem than other areas, but 'I think our data reflects what is going on nationally'.
THE DOH VIEW
STEPS TO SUCCESS
Department of Health chief scientific officer and national clinical lead for physiological measurement Sue Hill says there are a number of steps trusts should take to ease their way towards the 18-week target:
Identify PM services, who delivers them and the scale of the challenge.
Understand patient flows, pathways and referrals. Look at equipment use, hours of operation and processes to improve productivity.
Establish data collection and waitinglist management.
Map current workforce and consider skill mix and other options.
Assess likely impact of new technology and explore new delivery models.
Set up a PM group to share experiences and solutions, and adopt a common approach.
Many trusts are struggling to keep up with demand for physiological measurement.
A DoH PM leadership group has been set up to shape strategy. Trusts must report wait times to the group.
Skill mix and building on best practice are seen as potential solutions to capacity and planning issues.
For more information on PM go to www. good management-hsj. co. uk/ diagnostics.