7 Day Services: Applying the Lessons to Diagnostics Erika Denton National Clinical Director for Imaging - presentation from seven day services in diagnostics event held on 4 March 2013 #7dayDiagnostics

1. 7 Day Services:
Applying the Lessons to Diagnostics
Erika Denton
National Clinical Director for Imaging
March 4th 2013

2. 7-day working
• What do we mean by 7 day working?
• Why change?
• How?
• Co-dependancies
• Challenges

3. Open 24 hours?

4. Providing NHS Services 7 days a week
“7 days a week” : what does it mean?
• Traditionally maternity & A&E only
• Primary care access and elective work
• Secondary care pathways
• System wide approach essential

5. Norfolk & Norwich University Hospital
NHS Foundation Trust

6. Why should we change?
• ↓ cost & make best
use of resources
• ↑ demand vs capacity
• ↓ length of pathways
• ↓ waiting
• Patients want us to

7. Projected Rate Of Population Growth By Age Last Birthday
The vast majority of
increase in
16%
population over the
next 6 years is 14%
predicted to be in Under 60 (% increase from 2004)
the 60+ age bracket. 12% Over 60 (% increase from 2004)
10%
Projected Population
Increase from 2004 % 8%
6%
4%
2%
0%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Under 60 (% increase from 2004) 0.0% 0.5% 0.8% 0.8% 0.7% 0.9% 1.0% 1.3% 1.5%
Over 60 (% increase from 2004) 0.0% 1.4% 2.8% 5.6% 7.9% 9.8% 11.5% 13.1% 14.6%
Year
(Source: Government’s actuarial department).

8. Causes Of Death For Over 60s
In 2004 the deaths
80% of the people over X Diseases of the respiratory XI Diseases of the digestive
60 who died could be system
15%
system
4%
attributed to three
underlying causes V Mental and behavioural
disorders
II Neoplasms 3%
26%
VI Diseases of the nervous
system
3%
XVIII Symptoms, signs and
abnormal clinical and laboratory
findings, not elsewhere
classified
2%
IX Diseases of the circulatory
system All Others
39% 8%

9. Why did we have targets?
18/52, 2 week waits, 6 week waits etc etc
Aimed to take waiting times off the
agenda once and for all.
The Ideal in diagnostics?
A no wait system?
this will mean 7 day working….

10. ‘In God we trust. All others must bring data’
W. Edwards Deming,
physicist and quality improvement pioneer

12. 1 – Data refer to exams in hospital only. 1 – Data refer to exams in hospital only.
2 – Data refer to exams outside hospital only. 2 – Data refer to exams outside hospital only.

13. AP
R
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
O
C
T
15 key tests
09
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
15 tests >6 week waiters April 2006 – Dec 2012
N
1
AP 2
R
12
JU
L
12
O
C
T
12

14. -
AP
R
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
06
JU
LY
06
O
C
T
06
JA
N
07
AP
R
07
JU
LY
07
O
C
T
07
JA
N
08
AP
R
08
JU
LY
08
O
C
T
08
JA
N
09
AP
R
09
JU
LY
09
MRI
O
C
T
09
JA
N
10
AP
R
10
JU
LY
10
O
C
T
10
JA
N
11
AP
R
11
JU
L
11
O
C
T
11
JA
N
12
MRI >6 week waiters April 2006 - Dec 2012
AP
R
12
JU
L
12
O
C
T
12

15. -
AP
R
2,000
4,000
6,000
8,000
10,000
12,000
14,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
CT
09
O
C
T
09
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
CT >6 week waiters April 2006 – Dec 2012
C
T
11
JA
N
1
AP 2
R
12
JU
L
12
O
C
T
12

16. -
AP
R
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
06
JU
LY
06
O
C
T
06
JA
N
07
AP
R
07
JU
LY
07
O
C
T
07
JA
N
08
AP
R
08
JU
LY
08
O
C
T
08
JA
N
09
AP
R
09
JU
LY
09
NOU
O
C
T
09
JA
N
10
AP
R
10
JU
LY
10
O
C
T
10
JA
N
11
AP
R
11
JU
L
11
O
C
T
11
JA
N
12
AP
NOU >6 week waiters April 2006 – Dec 2012
R
12
JU
L
12
O
C
T
12

17. -
AP
R
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
O
C
T
Audiology
09
JA
N
1
AP 0
R
1
JU 0
LY
10
O
CT
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
N
1
AP 2
R
12
JU
L
12
Audiology >6 week waits Apr 2006 – Dec 2012
O
C
T
12

18. -
AP
R
5,000
10,000
15,000
20,000
25,000
30,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
O
C
T
09
Colonoscopy
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
N
1
Colonoscopy >6 week waiters April 2006 – Dec 2012
AP 2
R
12
JU
L
12
O
C
T
12

19. -
AP
R
2,000
4,000
6,000
8,000
10,000
12,000
14,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
Flexi
O
C
T
09
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
N
1
AP 2
Flexi Sigmoidoscopy >6 week waiters April 2006 – Dec 2012
R
12
JU
L
12
O
C
T
12

20. -
AP
R
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
O
C
T
Cystoscopy
09
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
N
1
AP 2
Cystoscopy >6 week waiters April 2006 – Dec 2012
R
12
JU
L
12
O
C
T
12

21. -
AP
R
5,000
10,000
15,000
20,000
25,000
30,000
0
JU 6
LY
06
O
C
T
06
JA
N
0
AP 7
R
0
JU 7
LY
07
O
C
T
07
JA
N
0
AP 8
R
0
JU 8
LY
08
O
C
T
08
JA
N
0
AP 9
R
0
JU 9
LY
09
O
C
T
09
Gastroscopy
JA
N
1
AP 0
R
1
JU 0
LY
10
O
C
T
10
JA
N
1
AP 1
R
11
JU
L
11
O
C
T
11
JA
N
1
AP 2
Gastroscopy >6 week waiters April 2006 – Dec 2012
R
12
JU
L
12
O
C
T
12

22. -
JU
50,000
100,000
150,000
200,000
250,000
N
E
SE 06
PT
06
D
EC
KEY: Blue = Activity
06
M
AR
JU 07
N
E
07
SE
P
07
D
EC
07
M
AR
Green = Number of patients waiting
JU 08
N
E
08
SE
P
08
D
EC
08
M
AR
09
JU
N
09
SE
P
09
MRI
D
MRI
EC
09
M
AR
JU 10
N
E
SE 10
PT
10
D
EC
10
M
AR
11
JU
N
11
SE
P
11
D
EC
11
M
AR
12
JU
N
12
SE
P
12
D
EC
12

23. -
JU
50,000
100,000
150,000
200,000
250,000
300,000
350,000
N
E
06
SE
PT
06
D
E
C
06
M
KEY: Blue = Activity
AR
07
JU
N
E
07
SE
P
07
D
EC
07
M
A
R
08
Green = Number of patients waiting
JU
N
E
08
SE
P
08
D
EC
08
M
A
R
09
JU
N
09
SE
P
CT
T
CT
09
D
EC
09
M
A
R
10
JU
N
10
SE
PT
10
D
EC
10
M
A
R
11
JU
N
11
SE
P
11
D
EC
11
M
A
R
12
JU
N
12
SE
P
12
D
EC
12

24. US
NOU
450000
400000
350000
300000
250000
200000
150000
100000
50000
0
06
06
07
08
09
10
07
08
09
0
1
11
2
6
7
8
09
10
1
07
08
09
10
11
12
C0
C0
C0
C1
N1
N1
N1
PT
PT
PT
NE
NE
NE
P
P
P
C
C
R
R
R
R
R
R
N
SE
SE
SE
DE
DE
DE
DE
DE
DE
JU
JU
JU
JU
MA
MA
MA
MA
MA
MA
SE
SE
SE
JU
JU
JU
Waiting List Acti vi ty
KEY: Blue = Activity
Green = Number of patients waiting

25. JU
N
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
E
06
SE
PT
06
D
EC
06
M
KEY: Blue = Activity
AR
07
JU
N
E
07
SE
P
07
D
EC
07
M
A
R
08
Green = Number of patients waiting
JU
N
E
08
SE
P
08
D
EC
08
M
A
R
09
JU
N
09
SE
PT
09
D
EC
AUDIOLOGY
09
M
A
R
10
Audiology
JU
N
10
SE
PT
10
D
EC
10
M
AR
11
JU
N
11
SE
P
11
D
EC
11
M
AR
12
JU
N
12
SE
P
12
D
EC
12

26. JU
N
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
E
06
SE
PT
06
D
EC
06
M
AR
KEY: Blue = Activity
07
JU
N
E
07
SE
P
07
D
EC
07
M
AR
08
JU
Green = Number of patients waiting
N
E
08
SE
P
08
D
EC
08
M
AR
09
JU
N
09
SE
PT
09
D
EC
09
Colonoscopy
M
AR
10
JU
N
10
Colonoscopy
SE
PT
10
D
EC
10
M
AR
11
JU
N
11
SE
P
11
D
EC
11
M
AR
12
JU
N
12
SE
P
12
D
EC
12

27. JU
N
0
5000
10000
15000
20000
25000
E
SE 06
PT
06
D
EC
06
M
A
R
KEY: Blue = Activity
JU 07
N
E
07
S
EP
07
D
E
C
07
M
A
R
JU 08
N
E
Green = Number of patients waiting
08
S
EP
08
D
E
C
08
M
A
R
09
JU
N
S 09
EP
T
09
D
E
C
09
M
AR
10
JU
N
Flexi Sigmoidoscopy
SE 10
P
T
10
D
E
C
10
M
AR
Flexi Sigmoidoscopy
11
JU
N
11
SE
P
11
D
EC
11
M
AR
12
JU
N
12
SE
P
12
D
EC
12

28. JU
N
0
5000
10000
15000
20000
25000
30000
35000
E
S 06
EP
T
06
D
EC
06
M
A
R
KEY: Blue = Activity
JU 07
N
E
07
S
EP
07
D
EC
07
M
A
R
JU 08
N
E
Green = Number of patients waiting
08
S
EP
08
D
E
C
08
M
A
R
09
JU
N
S 09
EP
T
09
D
E
C
09
M
A
R
Cystoscopy
10
JU
N
S 10
EP
Cystoscopy
T
10
D
E
C
10
M
AR
11
JU
N
11
SE
P
11
D
E
C
11
M
AR
12
JU
N
12
SE
P
12
D
E
C
12

29. JU
N
0
10000
20000
30000
40000
50000
60000
E
06
SE
PT
06
D
EC
06
M
AR
KEY: Blue = Activity
07
JU
N
E
07
SE
P
07
D
EC
07
M
AR
08
JU
N
Green = Number of patients waiting
E
08
SE
P
08
D
EC
08
M
AR
09
JU
N
09
SE
PT
09
D
EC
09
G astroscopy
M
AR
10
JU
N
Gastroscopy
10
SE
PT
10
D
EC
10
M
AR
11
JU
N
11
SE
P
11
D
EC
11
M
AR
12
JU
N
12
SE
P
12
D
EC
12

30. All 15 tests
All 15 key tests
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
06
06
06
07
07
07
08
08
08
09
09
09
10
10
10
11
11
12
12
07
08
11
12
09
10
11
12
PT
R
AR
R
PT
R
PT
R
R
E
EC
E
P
EC
E
P
C
EC
EC
EP
EC
P
EC
N
N
N
N
N
N
N
SE
SE
SE
A
A
A
A
A
E
JU
JU
JU
JU
SE
SE
SE
S
JU
JU
JU
D
M
D
M
D
M
D
M
D
M
D
M
D
KEY: Blue = Activity
Green = Number of patients waiting

31. Life in Diagnostic Services?
Just do more!!

32. 1 – Data include equipment in hospital only. 1 – Data include equipment in hospital only.

33. PET CT, CT, MR etc
Massive capital costs to run
just 40 hours a week
Possible to extend the day
and work 7 days
May reduce need for new
equipment

34. National Audit Office Report 2011
Managing high value capital equipment in the
NHS in England
• MR, CT, RT linacs
• VFM in purchase &
maintenance
• utilisation
• cost & performance data

35. Tools to effect change
• Accurate data: activity, capacity, reporting times
• Communication with commissioners → £!
• Communication within trusts: clinical &
managerial → £!
• Guidelines: NICE, collegiate etc
• Policy drivers: Stroke, Cardiac, Cancer, Paediatric

36. The New Vocabulary
QIPP
quality
Health & Wellbeing improvement
NICE Boards productivity
Quality prevention
Standards SHAs & PCTs
GP Commissioning
Choice of
Cancer targets
diagnostics
Nothing about me
NHS
without
The NHS Commissioning
me
Board
World class
NICE guidance etc
commissioning
Outcomes
framework
Any Qualified
Tariffs 18 weeks Provider
Choice

37. New NHS Structure
Monitor
Department of Health Care Quality
Commission
Health and Social
NHS Commissioning
Care Information HealthWatch England
Board
Centre
Clinical Clinical Local
Commissioning
Senates Groups Authorities
Providers

38. Suggested Way Forward
• Engagement of all stakeholders, providers & users
• Set expectations
• Patient choice very powerful
• Modelling with “pathfinder pilot sites” &
benchmarking

39. Service delivery model
In Patient
24/7 A&E
Stroke Strategy
Primary Care Increased Access
Extended Day +/- 7/7
Patient Choice
Diagnostics
Secondary Care delivery – Out Patient
Tertiary Care Specialist Care

40. The biggest challenge maybe our staff

41. Negotiation & influence
• Evidence for change
• Leadership, from above and within departments
• Enable rather than enforce culture shift
• Terms and conditions, contracts & employment law

42. Expected Benefits
• Improve primary & secondary care integration
• Share best practice
• Improve training out of hours
• Maximise capacity of current assets between
providers
• Reduce current inefficiencies & cost (in some
areas…..)

43. Rationale for a phased approach
Phase 1 - Urgent/Emergency & Inpatient Care
• Accident & Emergency
• Obstetrics & Gynaecology
• Trauma & Orthopaedics
• ITU & Anaesthesia
• Cardiology & Acute Medicine
• General Medicine
• Paediatrics

44. Build on Phase 1
Phase 2 - Elective & Outpatient Care
• Other specialties with large elective/outpatient workload
• Move from: extended week day work
weekend in patient
weekend out patient
? Ultimately no difference across 7 days

45. Co-dependant services
Transport, pts & staff
Domestic support &
social services
Childcare, staff & pts

46. 7 day pathways…
one cardiac patient . . . 10-day hospital stay . . .
…….six departments . . . 105 healthcare professionals
Scan ECG Echo/Contrast Catheter La Anaesthesia Monitoring Ventilation