The University Hospitals of Coventry and Warwickshire NHS Trust was able to work with partners in the local integrated care system to set up a shared patient tracking list and make inroads on the growing numbers of patients waiting for more than 18 weeks for treatment. It has also developed an approach which looks at outcomes rather than time on the list, and thus tackles inequalities.
What the organisation and system faced
UHCW went into the pandemic with zero 52 week waiters but a year later had 5,000. It also had a 53,000 long referral to treatment waiting list with around 24,000 having waited more than 18 weeks – whereas before the pandemic only 2,000 to 3,000 had.
Its problems were echoed by other providers within its integrated care system, Coventry and Warwickshire, which includes South Warwickshire NHS Foundation Trust and the George Eliot NHS Hospital Trust. The solution was a shared patient tracking list and ensuring patients got treatment in a way which minimised health inequalities – already made worse by the pandemic.
What the trust and wider system did
As in many areas, a shared PTL had been mooted before but enthusiasm had not been universal. However, the pandemic gave the idea a boost – in part because relationships across the system were deepened and trust built. “It was recognising that we were better working together across organisations leading to a better use of capacity as we did so,” says Professor Kiran Patel, chief medical officer at UHCW. “The pandemic has given us a sense of urgency and necessity.”
The shared PTL did a number of things: first, it allowed conversations about distributing patients across the system to where there was spare capacity in a specialty. One longer term possibility is the use of UHCW’s Rugby site – St Cross Hospital – as an elective centre serving the whole of the ICS area. This could stop the position where elective work is delayed by emergencies as often happens in specialties such as ENT.
Second, the shared PTL exposed a number of people who have been referred to multiple hospitals, either for a single condition or for different ones. This raises the question of whether they would be better treated at a single site or whether they will need a multidisciplinary approach either within or between hospitals.
Results and benefits
Over three months the trust has reduced the number of 52 week waiters by a quarter and the waiting list is going in the right direction. The trust would like to get to no 52 week waiters by the end of the year.
The approach to who should be prioritised for treatment during the restoration of elective work is nuanced – before time spent on the list was the key factor but not now. Patients are still treated in order of clinical priority but within the waiting list categories there are opportunities to look at the potential outcomes for patients rather than prioritising simply by when they were referred.
The trust is using data to pinpoint people who may suffer more from waiting - such as those who have co-morbidities or where their employment may be affected. This approach is backed up by an ethics board so as not to disadvantage any groups of patients. “I think equity is a very important principle and not just equity of access but equity of outcomes,” says Professor Patel.
It is developed and is also using a clinical harm tool to assess people at points on the waiting list and pinpointing those who are deteriorating.
But, as well as looking at people on the waiting list, it is proactively seeking people who may need treatment but have not come forward. The trust is working with primary care to find these people by using information from the local strategic needs assessment to discover areas where referrals are lower than would be expected from the needs of the population. “Otherwise, it becomes a very late presentation of disease and that is what drives poorer outcomes,” says Professor Patel. Vaccination sessions are also being used to spot early signs of cancers or cardiovascular disease by adopting a prevention and healthy lifestyle tool the trust has developed. “We are driving prevention and early intervention at scale,” he says.
The trust is also trying to reduce unnecessary pressure through increased use of patient-initiated follow ups and also managing more patients in primary care. However, it is doing elective work against the backdrop of extreme emergency pressures with demand for unplanned care at 126 per cent of the 2019 level. And staff, as everywhere, are exhausted after 18 months of the pandemic.
But there are challenges. The trust can bid for capital but there is little support for the revenue consequences of investment in capital projects such as staffing additional critical care beds: the consequence is taking staff out of other areas (which will reduce its ability to do other work) or using agency staff which will push up costs.
- The pandemic has created an opportunity to build deeper relationships and a sense of shared purpose which can overcome organisational loyalties and push forward longer-term projects.
- With those relationships in place, this may be the time to think about more radical changes, such as where is the right place to do much elective work and whether greater coordination of services could bring benefits.
- Tap into clinicians’ desire to do the right thing for their patients – proposals for cold sites may offer opportunities to carry out more planned operations without interruptions due to emergency work, for example.
- Where there are risks around workforce, an important consideration for the board is that developing these plans can offer a way to mitigate them rather than letting them materialise.
For more information about the work in this case study contact Prof Kiran Patel.
Find out more
Professor Kiran Patel discussed his trust and system's approach to elective recovery at a September 2021 webinar. Catch up on the conversation for further insights and practical points.
Integration in Action
This case study forms part of our Integration in Action series, a collection of publications, podcasts and webinars which explores how effective partnership working is helping to address the biggest challenges facing health and care.