The Target including explanation of some of the complexities by xarrnet


									                     ENFIELD PRIMARY CARE TRUST

Report:      18-Week Referral-to-Treatment (RTT) Plan

No:          EP 125/06

Date:        December 2006

There is a national target to achieve a maximum 18-week pathway for all patients by
December 2008.
This report has been developed to brief the Board of the timetable, risks and actions
being taken to mitigate risk. The plan is also in response to the fitness-for-purpose

Financial Impact:
The PCT has made financial provision to meet the target. A notable risk would arise
if the PCT were unable to spread much of its investment in meeting the target in
2008-09. Being able to do so would help to alleviate financial pressure in 2007-08.

Patient Perspective and Equality impact
The achievement of the 18-week target will result in significantly shorter waiting
times for patients. The patient experience should also be improved by the redesign
of patient pathways.

Workforce and Training Impact
The key deliverables to achieve this target will involve practice-based
commissioners. There will be protected learning time sessions and direct briefings
to practice-based commissioners and their staff on pathway re-design,
developments in Choose & Book, and referral management initiatives.

Monitoring Arrangements
Progress towards meeting the target and intermediate milestones will be reported to
the Board monthly as part of the performance report.
The Board is asked to note the contents of the report, the risks and the actions
being taken to mitigate risk.

Submitted by:            Liz Wise, Director of Planning & Commissioning

Author:                  Stephen Dixon, Assistant Director, Planning &
                         Commissioning (Acute)

December 2006                                                                -2-
                               18-Week Action Plan

1. Objective
Delivering an 18-week referral-to-treatment (RTT) patient pathway from GP referral to
the start of treatment by the end of December 2008 is a key objective of the NHS and
as one of the Selbie five.
Achieving the 18-week target is seen by PCTs in London as high risk. The basis
upon which patient waiting times need to be recorded and reported will change
dramatically. Delivering an 18-week maximum wait will require very detailed
planning, additional financial resources during a period of financial constraint and
will involve significant changes in methods of working to deliver the redesign of
patient pathways and implement demand management.
PCTs will be held directly accountable for the achievement of the 18-week pathway.
Although the target delivery date for 18-weeks is December 2008, the current Local
Delivery Plan (LDP) trajectories are set to achieve the target by early 2008-09 in line
with Department of Health expectations.
An Action Plan is needed to satisfy the requirements raised in the Fitness for
Purpose Review – within 30 days after formal letter signed-off by the PCT Chief
Executive. The Action Plan will need Board approval before submission.
The 18-week Action Plan will continue to be developed and will require revision over
Draft Local Delivery Plan (LDP) ‘Phase III’ trajectories to meet the December 2008
target have been to be submitted to the DoH on the 30 th November 2006. It is
understood that there will be the opportunity to firm up this trajectory in light of more
detailed performance information being made available to the PCT from all provider
In essence, the programme is based on monitoring ‘clock starts’ and clock stops’ on
a patient pathway. In a similar manner to monitoring cancer waiting times, the
performance data is based on monitoring each patient, not the average for a service
or specialty.
The 18-week RTT programme Timeline is attached as Appendix [1].
The following table outlines the dates by which the Healthcare Commission expects
the PCT to achieve a number of 18-week programme milestones:

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                    Mar 2006          Mar 2007         Mar 2008         Dec 2008

 Outpatients      Max 13 weeks     Max 11 weeks      Max 5 weeks
                                                                      Maximum 18
 Diagnostics      Max 26 weeks     Max 13 weeks      Max 6 weeks
                                                                      weeks in total
 Inpatients       Max 26 weeks     Max 20 weeks      Max 11 weeks

 ‘Admitted’                                           85% of total     100% of total
 Patients                                               within            within
 (18 wk RTT)                                           18weeks          18 weeks

 ‘Non-admitted’                                       90% of total     100% of total
 Patients                                                within           within
 (18 wk RTT)                                           18 weeks         18 weeks

The rules defining ‘admitted’ and ‘non-admitted’ patients for the purposes of the 18-
week programme are specified in DoH guidance.

2. Context
It is considered that there is plenty of physical capacity in the local health economy
to achieve the target.
The additional capacity (activity) to meet the 18-week milestones by the end of
2007-08 is as follows:
      Elective Inpatients – an additional 6%
      Outpatients          – an additional 3.5%
Meeting the 18-week target it is not simply a question of investing more money in
more activity. It should be a combination of investment and pathway re-design. This
will include the use of additional capacity where available, including making use of
the independent sector.
Due to funding constraints in 2006-07, investment towards the target is within 2005-
06 investment levels, less referral management savings initiatives. Nevertheless,
programmes to improve the management of referrals through the established
specialist clinical assessment service (SCAS) and, where necessary, ensuring
consultants refer back to primary care, will make a contribution towards the LDP
trajectory in 2006-07.
The 2007-08 financial year will be the most demanding year in terms of finance for
the PCT and capacity for the providers in reducing the 18-week RTT programme
maximum waiting times.
The Integrated Service Improvement Plan (ISIP) board has agreed that delivery of
the 18-week target will be the next project to be added to the works programme. The
existing outpatient project will contribute to achieving the 18-week target.

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3. Overview
The current waiting times position for inpatients, outpatients and diagnostics at the
end of October 2006 are as follows:
Type             Waiting - Total   2006-07 Waiting   Waiting above     Percentage
                                   – Threshold       Threshold         above Threshold
Outpatients           8,018           11 Weeks             557             6.95 %
Diagnostic            5,482           13 Weeks            1,099           20.05 %
Inpatients            4,509           20 Weeks             462            10.25 %

The Healthcare Commission expects that, by March 2007:
      97% of outpatients will have waited no more than 11 weeks to be seen
      97% of inpatients will have waited no more than 20 weeks
The PCT’s current LDP (‘Phase II’) planning trajectory suggests that only 95% of
outpatients and 91% of inpatients will be seen within these time limits. This LDP
trajectory is in line with the PCT’s current investment strategy.
The Healthcare Commission’s expectations for diagnostic waits are more stringent:
100% to be seen with 13 weeks. This is particularly challenging for the PCT as the
data above suggests there is currently a 20% gap to be closed by the end of the
financial year. However, analysis of the diagnostic waiting times in October 2006
indicates a marked improvement on average waits: from 7–8 weeks in May 2006, to
5–6 weeks in September 2006, although, as expected, there were marked variations
between specific services.
Two baseline exercises have now been completed early in the autumn 2006: the first
covered pathways that ended in a hospital admission and the second was for
pathways ending in an outpatient appointment. Both exercises were retrospective.
The baseline for admitted patients showed that only 27% of patients completed their
pathway in less than 18 weeks. As expected, the baseline for non-admitted patients
showed much shorter pathways with 87% seen within 18 weeks.
Part of the trajectory towards meeting this overall target was the indicator on waiting
times for MRI and CAT scans, which was included in the 2005-06 Annual Health
Check. The PCT achieved this with no patients waiting more than 26 weeks for their
scan. At the end of October 2006, there were no patients waiting longer than 21
weeks for an MRI or CAT scan.

4. Challenges, Risks and Actions to resolve

4.1 Financial
The HCC standards for 2006-07 requiring the PCT to meet an end of March 2007
milestone will add a significant risk to the PCT’s 2006-07 financial recovery plan.
The agreed capacity plan and service level agreements for 2006-07 have been
established on the basis of the LDP ‘Phase II’ trajectory. This trajectory assumes the
newly published year-end 18-week wait milestone will be missed and the additional
activity as may be required will be undertaken largely in 2007-08. The initial cost

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pressure to meet the published HCC standard has been calculated to be in the
region of £740K for inpatient and outpatient activity alone and does not include any
cost associated with ensuring no >13-week waits for a diagnostic by year-end.
The PCT’s Turnaround Board has been notified of the tension between the target to
achieve financial balance and the 2006-07 year-end 18-week milestone.
Although the DoH has published indicative tariffs for some radiological diagnostic
tests such as for MRI, CT and ultrasound, there is no agreed national tariff for the
wider range of diagnostic tests. Any ‘unbundling’ of the tariff is subject to local
negotiation with providers.
At the date of developing this plan, no guidance has been received from the DoH on
the cost of independent sector diagnostic tests under the national contract. There is
a risk that where the PCT may take advantage of independent sector diagnostic
capacity, there may be a differential tariff to be paid to the independent sector
providers. This may result in a cost pressure to the PCT.
Historically, consultant-to-consultant referrals were not counted as part of national
waiting time targets; consequently, a number of patients would often wait much
longer than the national outpatient maximum waiting time targets, which only applied
to patients referred by a GP. These consultant referred patients are now included
under the 18-week RTT definitions. This will result in a cost pressure to the PCT.
Delivery of the pathways will require significant investment in additional activity and
process improvement.
The PCT has made financial provision towards meeting the target. The extent to
which this investment will be required in 2007-08 and 2008-09 will depend on the
level of progress made in 2006-07. It also remains to be seen whether the
Department of Health will allow PCTs to revise their LDP ‘Phase III’ (2007-10)
maximum wait trajectories so that financial investment can be spread more evenly
across the months (and the financial year boundary) leading up to December 2008.
This would help alleviate the pressure on finance and capacity in 2007-08.
As more robust planning information becomes available - including any guidance for
the 2007-2010 Local Delivery Plan (LDP) – the PCT will be in a better position to
refine the estimated cost of progress towards the 18-week target and fine tune the
necessary budget to achieve the milestones for 2007-08.
4.2 Diagnostics
Diagnostics is generally accepted as the huge challenge in many respects as it is the
period of waiting which has not previously been measured. The top 15 diagnostics
have been measured since April 2006 and are slowly beginning to show a picture of
the challenges to be faced in reducing the waits in this area.
There are some patients waiting a long time for some diagnostic tests; for example,
peripheral neurophysiology (77 waiting between 51 and 52 weeks), urodynamics (19
waiting over 52 weeks) and cystoscopy (18 waiting over 52 weeks). In addition to
pathway and referral management initiatives, the diagnostic waits are being
incorporated into the Benefits Realisation Plan of the Outpatients Change
Programme of the local health economy Integrated Service Improvement Programme

December 2006                                                                      -6-
Local provider trusts are undertaking a review of patients on all their waiting lists,
including that for diagnostic tests. This is serving to eliminate patients who no longer
require a diagnostic test and who may also account for a number of the longest
Maximising the use of the independent sector diagnostics programme will enable
patients to be diagnosed faster and referred to the most appropriate setting for
Additional capacity for echocardiography is being established in the community at the
Forest Primary Care Centre.
InHealth Netcare (the independent sector diagnostics programme provider) direct
access diagnostics contract, is presently being mobilised to start its services with
effect from April 2007 and will provide MRI; X-ray; echocardiography and ECG tests.
InHealth Netcare will be establishing a mobile x-ray service for two days a week at
the Forest Primary Care Centre. The remainder of the services will be provided from
their Kings Oak hospital on the Chase Farm site. This will be transferred activity at
cost to the PCT and will require reductions in any direct access provision from
established providers.
The PCT is also taking advantage of unused capacity available via the DoH
commissioned InHealth Netcare (Amicus) mobile MRI contract, which is now in its
third year (of a five year contract). This contract provides additional MRI capacity at
no additional cost to the PCT. Previously, access to this mobile service was used
exclusively to reduce provider trust MRI waiting lists. However, Enfield PCT is
trialling an access scheme via the SCAS and has there is an opportunity to continue
to access any spare capacity over the remaining years of the contract.
4.3 Information
The development of provider trust information systems to enable the collection of
relevant data required to monitor whole system pathway waiting times is a risk. This
is particularly relevant for Barnet Chase Farm Hospitals NHS Trust as they employ
two different patient administration systems. The North Middlesex have a similar
PAS to Chase Farm hospital and there is the opportunity for both trusts to s hare
operational solutions in capturing 18-week data.
The PCT is working with both B&CFH and NMUH to identify any high-risk areas and
to develop strategies to address these risks.
The PCT is continuing to working with the local hospital trusts to identify which
clinical pathways will present the greatest risk in absence of robust performance
data. The PCT and the Trusts will also be working to identify any critical areas that
might create a risk to meeting the 18-week target. Efforts will be focused to reduce
waiting times and to avoid any bottlenecks.
An 18-week baseline exercise was undertaken during September 2006 that used
data from 2005-06. The DoH have reported that the baseline may have up to a 15%
error factor due to a number of technical issues.
There is a risk that some providers cannot provide 18-week RTT data if they are (a)
not sufficiently advanced in developing their in-house data collection processes for
manually recording ‘clock stops’, (b) rolling out data collection across all outpatient
specialties and (c) enhancing their patient administration systems to enable

December 2006                                                                       -7-
electronic reporting of 18-week performance. The first comprehensive 18-week RTT
reports will not be available until mid March 2007. Consequently, there is a risk
associated with developing detailed 18-week trajectories to meet the target in the
absence of detailed local performance information.
No centrally developed tools to support the establishment of the 18-week trajectories
are available. The PCT will, therefore, be working with other PCTs to develop these
tools and share best practice.
Further analysis of the 18-week RTT baselines is to be undertaken when more
comprehensive monthly data comes on-stream to identify problem areas and
bottlenecks to ensure Enfield is on track to meet the 2008 target
The PCT participates in 18-week delivery meetings both locally and regionally.
4.4 Capacity
As part of the 2007-08 commissioning round, the PCT will be engaging proactively
with providers to ensure capacity planning is robust.
The PCT will be using the newly developed health informatics Shared Service
(performance management) PUMA system to identify levels of additional activity
which may be required by specialty and to commission on this basis; taking account
of referral management initiatives and the effectiveness of the programme
Current capacity and use of resources are changing in light of demand management
initiatives by all commissioners; in the case of Enfield PCT, through the extension of
the SCAS for triaging all non-urgent GP referrals and follow-up outpatient lists
without a TCI date. Financial turnaround processes by providers are also adjusting
capacity and service provision in response to commissioner initiatives and to meet
their turnaround plans.
The PCT will also develop market intelligence to ensure the PCT fosters
relationships with a range of providers, both NHS and independent sector, capable
of supplying additional capacity in relevant clinical areas as may be required.
The PCT will be utilising alternative providers, including in the independent sector,
where there may be insufficient NHS capacity to achieve the requisite throughput of
patients to meet the 18-week target and the milestones – this may be for specific
diagnostic tests or targeted procedures.
4.5 Pathway re-design
Through ISIP and demand management initiatives the PCT is developing new, more
efficient care pathways across primary and secondary care, which result in shorter
waiting times, using national best practice and local intelligence to identify the
relevant key areas. This will include but is not limited to:
      Utilising available capacity more effectively; including the work-up of patients
       before referral;
      Maximising the use of the independent sector diagnostics capacity from April

December 2006                                                                       -8-
      Taking full advantage of the elective and diagnostics capacity that will be
       available via the ‘Wave 2’ independent sector elective programme as the
       capacity becomes available from early 2008-09; and
      Through the practice-based commissioning process, the PCT will Identify
       clinical champions in both primary and secondary care who will help to drive
       the development of new care pathways in key areas.

4.6 Demand Management
While the current forecast for 2006-07 is a 3.5% reduction in GP referrals against
2005-06 outturn, the PCT’s Specialist Clinical Assessment Service (SCAS) is due to
expand its scope of operation to triage all non-urgent referrals before the end of
2006. It is estimated that this will result in a reduction of at least 10% of referr als
across all specialties. This will result in a part-year impact on referral levels in 2006-
07, with a full-year effect in 2007-08.
The consultant-to-consultant protocol is being developed further to ensure that a
defined scope of activity is referred back to primary care for review. This will be one
of the one of the pan-London initiatives as part of the 2007-08 commissioning
Although the urgent care and long-term conditions ISIP plans will not be a significant
feature of the 18-week RTT, they will nevertheless contribute towards the target by
minimising emergency admissions, which, in turn, will ensure that elective capacity
can be maximised towards achieving the 18-week RTT target.
In summary, the PCT’s admission avoidance programmes will make it easier to
achieve the 18-week RTT target by:
      Fewer patients being admitted to an acute setting through improved
       management in the community
      Clinically reviewing referrals to ensure patients are treated in the most
       appropriate setting
      Developing evidence-based policies to ensure appropriate access to a range
       of procedures that is affordable
      commissioning speedier access to diagnostics to support referrals

4.7 Performance monitoring
The PCT will ensure that progress towards the target is monitored closely within the
PCT and any deviation from trajectories will be highlighted at the earliest possible
A performance reporting system will be developed so that PCT management and
the Board are kept informed of progress towards the target on an on-going basis.

4.8 Independent Sector Capacity – 2008-09
The London-wide ‘Wave2 elective’ contract, for which the preferred bidder is due to
be announced later this month, is due to start in April 2008. This programme has the
potential to contribute significantly towards delivering the 18-week RTT target. The

December 2006                                                                         -9-
contribution will primarily be due to shorter access times contributing towards shorter
patient pathways; however, activity costs will be at tariff.
Nationally, there are long waits for direct access audiology services; it is therefore
planned that there will be a separate national procurement for this diagnostic test.
Both the ‘wave 2’ elective programme and direct access audiology scheme are to be
part of the ‘extended choice network’, the PCT will, in due course, need to monitor
the impact of these independent sector contracts on local health economy providers.
The PCT will take into account the indicative activity levels to the independent sector
when negotiating contract levels of activity with NHS providers for 2007-08 (direct
access diagnostics only) and for 2008-09 (a fuller range of activity).

5. Risk Analysis
This will be developed in more detail; however, the following issues have been
identified as a risk. A mitigation plan will be developed by the end of January 2007.
The analysis will include the following issues:
    Affordability
    Capacity
    Data
    Pathway Re-design
    Demand Management
    Achieving Milestones
    Achieving Targets
    Clinical Engagement
    PPI
    Tariff ‘Unbundling’
    Management Capacity

6. Summary of the 18-week Implementation Framework

(a) PCT key actions:
     Commission best pathways
     Implement ISIP
     Performance manage Trusts on delivery of choice of scan
     Validate national waiting times data
     Achieve local stage of treatment milestones
     Implement referral to treatment measurement systems in collaboration with
     18-week baseline exercise completed
     Report on progress towards achievement of 18 weeks
     Use the model contract to support delivery

December 2006                                                                      - 10 -
      Performance manage all providers through the contract
      Manage local service provision
      Promote the use of choose & book
      Reduce waits for therapies

(b) GP & referrers key actions:
     Use Choose & Book
     Refer using agreed local protocols and best practice
     Use PbC to drive the patient pathways
     Create proactive processes to help patients move quickly through pathways
     Move appropriate services into primary care.

   7. Conclusion
   The challenge to the PCT in achieving an 18-week referral to treatment maximum
   wait for all patients by the target date should not be underestimated. There are a
   number of significant risks to the PCT in delivering the target, which have been
   highlighted in this plan.
   The PCT ‘s progress towards meeting the18-week RTT milestones and target will
   be reported to the Board on a monthly basis. The report will provide an indication
   of the percentage achieved against the relevant milestones, which will reflect
   compliance with the Healthcare Commission standards.

December 2006                                                                    - 11 -

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