From response to recovery in elective care: five…

Trusts are facing a clinical risk dilemma as they turn their attention to the recovery of elective care. They need to decide which patients to treat, in what order, in which setting and whether it is safe for staff to deliver this care. As elective care returns, a structured approach to tackling their waiting lists will be critical to both performance and patient outcomes.

Trusts will be well aware of the sizeable challenge wait lists present after several months where focus has been diverted to COVID-19. Managing this task will draw on many traditional tools and processes such as waiting list validation and capacity planning, but will also require new approaches or greater emphasis than before into specific areas.

As we have mentioned before, the unprecedented environment created by COVID-19 means that conventional wisdom for our industry can no longer be relied on to inform the future path. This blog, focusing on waitlist challenges, is the latest in our series of ‘response to recovery’ viewpoints focused on elective care. They are intended to provide NHS leaders with some key considerations to help inform their return to delivering elective care.

Using data to manage harm

Following the immediate COVID-19 response period, each Trust’s waiting list will include numerous patients who can no longer progress with their operation immediately or at all. This may be because they are now sick or in the worst case, deceased.

For the patients that remain on the waiting list, Trusts need to understand where the greatest risks of harm exist and how capacity should be prioritised to address it. Risk stratification of the waiting list will require a blend of data analytics and clinical judgement.

An even more complete view of which patients to prioritise, will come from employing a risk stratification exercise and clinical review. Trusts can then initiate low risk elective activity with low risk patients to test the water on how they can manage recovery alongside COVID-19. For example, in Outpatients where infection risk is deemed lower.

At the other end of the spectrum, patients will also need to be stratified to determine which are most suitable for video or telephone consultation. This may be down to clinical factors such as the requirement for examination or outpatient procedure, or down to patient-led factors. The patients will need clinical review to bring out the richness of the referral information and previous assessments. Clinical capacity will need to be planned to support this.

Improving patient experience

Trusts have an opportunity to improve patient experience and reduce anxiety and uncertainty for anyone who has been on the waiting list for a significant period and may not have received an update on the likely future date of their outpatients appointment, diagnostic or procedure. Some patients may also be considering removing themselves from waiting lists based on a perceived personal risk of infection in current circumstances.

As elective capacity comes back online in a phased way, admin staff who aren’t booking patients at usual levels have an opportunity to focus on calling waiting list patients and providing updated information and reassurance. This could also be used as an opportunity to assess which patients might be comfortable with video or telephone consultations instead of in-person. As well as pre-empting or discussing further any decisions to cancel appointments based on concerns about infection. In addition to administrative contact, clinical advice lines can be established as additional clinical capacity from Clinical Nurse Specialists (CNS) and non-consultant grade Doctors becomes available.

Booking errors, or Appointment Slot Issues (ASI), should be closely monitored throughout the period to understand areas of continued capacity deficit due to COVID-19 and areas where the accumulated backlog requires additional short-term capacity or poling needs to be reviewed.

At a fundamental level there is an opportunity to create more “patient power”. Patients can be given the power to update their own COVID risk, their inclination to continue the pathway and their comfort with video and telephone consultations. The patient can take more control of their timeframes and methods of consultation with advice from their GP and Consultant about what is safe. Patients and families can also be involved in their risk stratification via collaboration tools like Microsoft Teams.

Gripping additions to the waiting list

Tight management of referrals and additions to the waiting list will be required to mitigate further delays and ensure that urgent cases that have accumulated are fast-tracked.

One way to manage this is for clinicians who are not running Outpatients and Theatres sessions, and no longer redeployed into COVID-19 support, to rigorously triage new and existing referrals. Trusts need to ensure they are using this specialist capacity for genuine clinical triage and not on the criteria-led administrative triage that can be delivered by non-clinical colleagues inside or outside the acute.

Another is for cases that have been delayed and are identified as a priority by primary or secondary care clinicians, or routine slots from e-referral services to be redeployed into GP advice and guidance. This will help to ensure that conditions which have been, or can be, effectively managed via self-care, primary care or remote methods aren’t added by default to an acute waiting list after COVID.

Alignment with capacity and workforce planning

Trusts need to ensure they conduct a rapid read-across between their model for tackling the waiting list and the availability of capacity and workforce to support it, given COVID commitments. This will require new planning mechanisms and multi-disciplinary teams. For example, management of complex surgical patients through their pathway will need to be closely aligned with projected availability of intensive care unit (ITU) bed capacity and suitable Anaesthetist capacity for pre-operative assessment and theatre time. Rotas across elective and COVID-19 commitments will need to be carefully managed to minimise clashes.

We should expect to see use of the Independent sector to support delivery of elective activity with capacity block booked by NHS England for three months. But modelling will need to be dynamic to reflect the changing volumes of COVID activity in this timeframe and beyond.

Waiting list trajectories will be interdependent with COVID-19 activity

Waiting list management has traditionally involved setting recovery trajectories based on enhanced capacity plans and forecasting of additions to the waiting list based on historic activity. The main challenges with this approach have then been fluctuations in demand or in capacity utilisation which are hard to predict.

After this first wave of COVID-19 no one knows with confidence exactly how further COVID-19 activity and the associated capacity requirements will play out - the flexible models and tools that we are deploying with our clients reflect this. The impact will be felt in the availability of capacity to serve the waiting list and so the waiting list trajectory. We do not know how much latent demand has been stored up by patients themselves or by primary care which will now hit the waiting lists and what the profile of this could be. Another reason why modelling and targets will need to be more responsive and dynamic to evolving circumstances.