Commissioning `endoscopy Services

1. Commissioning `endoscopyServices Debbie Johnston Wednesday 6th February 2015, ICC, Birmingham

2. Learning objectives • Understand the current situation and challenges • Examine what makes a quality endoscopy service • Plan and develop effective and efficient colonoscopy services • Understand the key challenges, common problems • Understand how planning and productivity will support successful business cases

3. Quality Services • Are we all clear what a quality endoscopy service looks like?

4. Endoscopy Services • Patient centred with good access to services • Coordinated with efficient access & processes • Cost effective offering value for money services • Staff with good skills and knowledge • Safe, low risk facility and environment • Uses standards and guidelines to continually improve safety and quality of care and the environment • Quality improvement culture supported by leaders and managers

5. Starting point In order to plan ahead effectively and commission efficient and safe colonoscopy services you need to understand clearly your starting point and where you are going to

6. True Statements? • We understand the current situation • There are robust standards and guidelines to cover all we need to commission effectively • Services work in the best and most efficient way • Commissioning colonoscopy/endoscopy is easy and we are ready for the future and can plan for whatever happens!

7. Drivers and pressures Targets: Cancer ‘journey’ time targets , 18 weeks Plurality of provision Demand • Bowel cancer screening Patient choice Financial flows, PBR, costs Capacity Diagnostics is key

8. Current situation: message one • Colonoscopy demand (activity) is increasing and will do for some time to come • How do we know this?

9. Endoscopic activity growth in Colonoscopy and flexible Sigmoidoscopy. These procedures are labour intensive and require a high degree of skill making them a significant growing bottleneck. 15% annual increase projected Although DM01 data gives a more timely snapshot of activity growth and waiting times, HES gives a more complete picture of lower GI Endoscopic activity

10. Current situation: message two • Colonoscopy Activity (surrogate for demand) has been rising and will continues to rise • Demand will rise further for good reasons: • More symptom awareness NAEDI • Increased colonoscopy activity/interventions rates • UK low compared to comparable nations (colonoscopy) • Age extension and Flexible Sigmoidoscopy Screening • Replacement of Ba enema • Pressure on waits is still a brake on demand • Makes health economic sense

11. Current situation: message three • The current problem is exacerbated because hospitals and units react tend to react to todays problem to rather than plan & commission for more demand • Many hospitals use short term measures such as waiting list initiatives to reduce waits • There is limited planning more capacity to prevent the problem recurring • Better planning is less costly and will reduce the risk of losing control of waits

12. Cost of waiting list initiatives and new consultant appointments • N and N = £50/point = £600/list • 125K for a new consultant (includes on costs) • PAs devoted to endoscopy and 42 week annualisation • 6 PAs £500/list • 7 Pas £425/list Better planning and efficency required……

13. Avoidable deaths pa if survival in England matched the best in Europe We need to do more Colonoscopy Data derived from Abdel-Rahman et al, BJC Supplement December 2009

14. Scenario 1: Current colonoscopy workforce must pick up all the slack = increase in colonoscopies/endoscopist if no change in workforce Cells in orange represent a 50% increase in activity per colonoscopist relative to 2010/11 levels. Cells in yellow represent years where activity exceeds 300 per colonoscopist (i.e. 6 procedures x 50 weeks.)

15. Scenario 2: The number of extra colonoscopists needed to deal with the added pressures (relative to 2010 baseline) if each did 210/year (Assumes that colonoscopists undertake 210 procedures per year. In 2010-11 colonoscopists did an average of 170 – 240 procedures per year. Our assumption requires colonoscopists to increase workload to 210 pa before more can be hired.)

16. Service Challenges Booking systems Prep Consent issues Patients flows Patients & staff not in the right place right time. Data & I.T. Referral processes Post Information Performance management information Discharge practices Pre ~ Peri ~ Post procedure Admission Variations in protocols/ guidelines Discharge Admin Follow Up G.P/Outpatients. Productivity Scheduling Kit issues List Backfilling Delays with Results before discharge & reports to G.P, Increasing waits Productivity & efficiency issues

17. Summary: Commissioning Lower GI endoscopy services • Action is needed now: • To improve existing waits • To prepare for the longer term need to expand endoscopy capacity. • This will save lives and will be highly cost effective.

18. Commissioning colonoscopy What do commissioners want? • To ensure patients receive the right test at the right time and in the most clinically appropriate local setting; • To ensure tests are appropriate, necessary, clinically correct, of high quality, with timely access and reporting. • To enable patients and referring clinicians to access a choice of provision according to patient choice, clinical need and relevant care pathway; • To operate to evidence based pathways covering the defined presentations and conditions delivering safe, person centred care;

19. Contin… • To ensure that the workforce is competent • To ensure testing is integrated across pathways of care, that the report and images follow the patient and that there is no unnecessary duplication of investigation • To collect and publish audit data on a variety of performance, service user and quality criteria • Work collaboratively with the commissioners to implement service development

20. Commitment • Commitment to the patient experience • Commitment to quality • Commitment to timeliness • Commitment to efficiency • Commitment to the team Commissioners, teams and organisations all want the same thing, it’s the perspective that’s different

21. Commissioning new services : Planning NEEDS ASSESSMENT • Statistics/data • Identify unmet need? REVIEW SERVICES • Service mapping • Gap/capacity analysis • Identify service improvements DECIDE PRIORITIES • Development of strategic plan • Resources/budgeting • Involve users

22. Commissioning: Service procurement/expansion DESIGN SERVICES • Development/expansion of service model • Service Objectives • Involve service users and carers CAPACITY PLANNING, DEMAND MANAGEMENT • Strategies for demand management • Resource utilisation • Future capacity requirements • Service specification • Support & encourage providers to develop services • Invite NHS/private/3rd sector providers SHAPING STRUCTURE OF SUPPLY

23. Commissioning: Monitoring & Evaluation Stage MANAGING PERFORMANCE • Agreed targets are met • Improvement plans SEEKING PATIENT/ PUBLIC VIEWS • Patient outcomes & experiences • Informs commissioning actions

24. Applicable national standards e.g. NICE, Royal College National and local policies and guidelines, including: • Care closer to home • Joint Advisory Group for gastrointestinal endoscopy • NICE guidance for Gastrointestinal endoscopy including • The Cancer Strategy – CG 27 on referral for suspected cancer3 • British Society of Gastroenterology5Pan Dorset referral and practice guidelines. • Our Health, our care, our say: a new direction for community services http://www.thejag.org.uk http://guidance.nice.org.uk/CG27 http://www.nice.org.uk/nicemedia/pdf/CG17NICEguideline.pdf http://www.bsg.org.uk/clinical/general/guidelines.html

25. Service Specification- JAG Accreditation The patient is our most important concern (level 1) The two domains of the GRS indicate how well we care for patients (level 2) A highly effective and efficient workforce underpins this high quality care (level 3).

26. Service Challenges Booking systems Prep Consent issues Patients flows Patients & staff not in the right place right time. Data & I.T. Referral processes Post Information Performance management information Discharge practices Pre ~ Peri ~ Post procedure Admission Variations in protocols/ guidelines Discharge Admin Follow Up G.P/Outpatients. Productivity Scheduling Kit issues List Backfilling Delays with Results before discharge & reports to G.P, Reduce waits Improve productivity & efficiency

27. Planning & productivity of a colonoscopy service • Key productivity-related objectives: • Demand and capacity • Waiting list management • Booking and choice • Performance and productivity • Workforce

28. PPAT - National Overview by Rooms

29. Key national challenges • 53% of services reported: • Poor or absent development plans in anticipation of future demands • Insufficient flexibility in the job plans of endoscopists to enable backfilling of funded capacity • 52% of services do not apply robustly the Appropriateness standard of the endoscopy GRS. • Vetting and validation practices are not clearly defined and there is inconsistency for new and surveillance procedures • 42% of endoscopy units do not routinely collect data to identify capacity constraints and to improve the productivity of the service.

30. Key concern • Of particular concern is the lack of forward planning because there is insufficient information on which to make decisions. • Business planning is generally weak

31. Demand and Capacity objectives

32. Performance and Productivity

33. Core Endoscopy Service Management • Appropriateness-guidelines, referral proformas & vetting • Clinical and admin validation (surveillance) • Clear Capacity Calculations for each list/endoscopist? • Productivity and utilisation • Capacity planning and management How are services organised for all of these now and for the future?

35. Provides detailed level view on; Start and finish times, list utilisation and Turnaround times

36. Workforce

37. Messages for commissioners • Commissioners should better understand the impact of endoscopy on clinical outcomes and the future demand for endoscopy, particularly from bowel cancer screening • They should work with endoscopy teams and provider organisations to agree future demand and make plans for meeting it • Should demand to see evidence of effective vetting against guidance and of high productivity

38. Messages for endoscopy teams and their organisations • Endoscopy team leads must work more collaboratively with their organisations and commissioners to achieve joint understanding and responsibility for the planning, business development and improvement of the service • More widespread adoption of processes and IT systems for collection of data on demand, capacity, utilisation and booking. • All units that are not obviously in control of their waits (manifest by long waits in HES, DM01 or GRS) should complete the PPAT online at least annually with an appropriate action plan.

39. Messages for endoscopy teams • Development plans for the workforce should anticipate future demands • The Appropriateness standard of the GRS must be applied robustly. Vetting and validation practices should be more clearly defined and more consistently applied • Process improvements recommended by NHS improvement should be routinely applied (Endoscopy-rapid review 2012).

40. End point In order to plan ahead effectively and commission efficient and safe colonoscopy services you need to understand clearly your starting point and where you are going to