13.06.17
What really determines how quickly we access healthcare?
Source: NHE Jun/Jul 17
Suzanne Bates has almost 20 years’ operational experience in the NHS and now works for NHS Improvement. She considers whether focusing on the profession of administrative care might improve access to healthcare while optimising the use of resources.
NHS headlines normally revolve around doctors, nurses, beds, performance against standards and finances. However, we rarely hear about what binds those elements together – the administrative staff of the NHS. They bear significant responsibility in moving patients along their pathway of care, towards treatment and wellness, which they do against a host of challenges.
Once a GP refers a patient to a specialist, it is the patient’s right to be seen and treated within 18 weeks. It is the administrative staff at the specialist’s end who must receive that referral and add it to the information system, but this is not easy. These referrals come in a variety of ways: some are emailed or entered directly via integrated information systems, others are paper forms posted in. Although we live in an age of apps-for-everything and real-time updates, a large proportion of referrals are still sent in by fax, an antiquated technology redundant in most other industries, and prone to loss of information. Referrals also have to be clinically prioritised, a rate-limiting step carried out by a clinician.
By this point, there is an obvious risk that some referrals are lost or temporarily delayed. At the very least, variation in method and a dependency on other parties make it impossible to process a steady stream of incoming referrals in order of their arrival. This is the first wave of churn in the system.
Once prioritised, patients are scheduled for a first outpatient appointment. The majority will be treated at a first or subsequent outpatient appointment; straightforward as long as medical records are accessible to clinicians at the time of the appointment. For patients requiring an admission for treatment, there are further layers of complexity.
The referral-to-treatment (RTT) coding system, used to signify where a patient is in their pathway to treatment, is not user-friendly. In an attempt to capture more detail, the system has been laboured with several codes to represent a variety of outcomes. There is a risk that the administrator, confronted with a long list of complex statuses, will either select the ones they are familiar with, or ‘other’, in the same way that we might react to an oversized drop down list. These codes determine where the patient will appear on the information system, and how they will be actioned. Incorrect RTT statuses can result in patients being seen and treated later than they could have been, because their record appeared in the wrong place.
The next challenge is the lack of communication with downstream resources (wards and theatres) to understand capacity. The highest priorities when scheduling are clinical urgency and how long the patient has waited. The next consideration is a clinician’s capacity to treat on the scheduled date, and normally, an assumption is made that beds will be available to match that clinician’s capacity. This often results in cancellations on the day of treatment or last-minute rescheduling, which is not only distressing for the patient, but also increases the level of risk in the system. That patient goes back into a queue already laden with risk, resulting in increased waiting times, whilst the conditions of some patients worsen. This is the second wave of churn in the system.
If a patient is having surgery, they usually require a ‘pre-assessment’ to check that they are fit for anaesthetic. Normally, the administrator secures a surgery date, then schedules the pre-assessment a couple of weeks beforehand – not so early that good results become obsolete, not so late that bad results won’t materialise in time for the patient to be told not to come in. They can then be made fit for a later surgery date, still within 18 weeks of referral. The seamlessness of this process depends on clinic capacity, the patient’s attendance and communication of negative results promptly to the administrator.
Our army of NHS administrators must keep on top of this, amidst monitoring their lists for long waiters and keeping abreast of emailed/faxed/telephoned communications to inform how they should action various patients.
To make sure appointments are kept, it is essential that letters reach their destinations and text reminders are sent, or patients are phoned (another administration job). If patients need to reschedule, their calls must be answered or returned in a timely manner by administrators, who are already caught up in waves of churn.
There is talk of consolidating and scaling down such staff, eventually automating their processes. However, to do this would require not only technology, but a greater degree of perfection in the operational processes outlined above, which are prone to random events.
Is it possible that the complexity of these jobs is not fully understood and appreciated? One solution to improve access to healthcare, and optimise the use of resources, might be to focus on the profession of administrative care.
Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of NHS Improvement.
Tell us what you think – have your say below or email [email protected]