Waiting list targets
NHS Plan waiting list targets:
· By end of 2005, patients should not wait more than six months for
elective surgery (measured from time of diagnosis)
· By end of 2008, patients should not wait more than three months
for elective surgery (measured from time of diagnosis)
NHS Improvement Plan waiting list target:
· By 2008, patients should not wait more than 18 weeks from GP referral
to elective surgery |
Treatment centres are changing the delivery of care for patients
requiring elective surgery in England. The centres (previously called
diagnostic
and treatment centres) were announced in the NHS Plan1 in 2000. They
form part of the modernisation agenda and are intended to increase acute
capacity and so help to meet the NHS Plan waiting list targets and the
tighter target in the NHS Improvement Plan2 (see
Panel).
Treatment centres (TCs) are essentially fast-track surgical centres.
They are designed for day case or short stay elective surgery. Some also
carry out diagnostic procedures, such as endoscopy, ultrasound and echocardiography.
The centres are intended to deliver a high volume of activity in a predefined
range of routine treatments and diagnostics to meet local demand. Separating
scheduled (elective) surgery from emergency surgery means that cancellation
of planned operations because of seasonal demands and emergency cases
is unlikely. In theory, too, the availability of a TC will speed up treatment
for patients admitted to emergency care by relieving pressure on beds.
The development of treatment centres can be seen as a step towards provision
of three levels of care:
· GP-led care (including walk-in centres)
· Treatment centres for uncomplicated elective surgery
· Hospital care, with the availability of an intensive care unit, for
more complicated elective surgery and emergency care
Some of the TCs are run by the NHS and some by independent companies
(independent sector treatment centres, ISTCs), but all are for NHS patients.
Treatment centres are essentially fast-track surgical centres |
The
Department of Health describes TCs as dedicated units offering safe,
fast, prebooked day and short-stay surgery and diagnostic procedures
in specialties that have traditionally had the longest waiting times,
for example, orthopaedics and ophthalmology. Surgery carried out in
the centres includes hip and knee replacement, minor orthopaedic surgery,
hernia repair and gall bladder and cataract removal.
The DoH says that core objectives of the TC programme are:
· To improve access to acute elective
care
· To modernise the way the NHS provides
diagnostic and elective care
· To drive productivity gain by stimulating
new models of service delivery The NHS Plan announced that 20 TCs would be developed by 2004. In the
event, in December 2004 there were 28 NHS TCs and six ISTCs (offering
a full or interim service) in England.3 The latest estimate is that by
the end of 2005 there will be 80 TCs: 46 NHS-run centres plus 34 centres
run by the independent sector.2
TCs are established (or planned) throughout England, with particular
clusters in some areas, including Greater London, Greater Manchester,
Cheshire and Merseyside, Birmingham and Hampshire. They provide services
across traditional organisational boundaries.
Day surgery constitutes a large proportion of the elective surgery currently
taking place in TCs but the TC programme is separate from the Government’s
day case programme (which is aiming to encourage more day case surgery,
from the current 40 to 50 per cent of all elective surgery to around
75 per cent).
Different models
TCs are run either by the NHS (mainly by acute trusts, but some by
primary care trusts) or are commissioned by PCTs from private sector
providers.
There is a wide range of different models of TC, dealing with a
variety of specialties and funded in a variety of ways. Some are in purpose-built
premises, others in existing or refurbished NHS facilities, and some
are mobile surgical units. The DoH also describes certain “virtual
centres” where, for example, there is no specific centre but a
number of units contribute to the elective surgery programme.
There are different referral routes into a TC. For example, in some places
a patient is referred to a specialist in the acute hospital who decides
whether they will be suitable for the TC (ie, that their surgery is expected
to be uncomplicated). Patients may also be transferred to a TC from another
hospital’s waiting list and some GPs refer patients direct to the
TC — this last referral route might increase from December 2005
when GPs are meant to be giving all patients a choice about where they
are treated.2
Eventually, when electronic booking systems are in place, there is likely
to be direct GP booking of a place in the TC theatre schedule.
The DoH defines three different types of TC:
· Entirely NHS
· Entirely independent sector
· Joint ventures, which may be either NHS or independent sector led
At present there is only one joint venture. This is the Redwood Centre
in Redhill, Surrey, which is managed by BUPA with NHS staff.
At Kidderminster in Worcestershire there will be two TCs — one
NHS centre and one ISTC — in the same building (on the site of
the Kidderminster Hospital) and using the same facilities but running
separately. The ISTC will carry out orthopaedic surgery while the NHS
TC includes a primary care centre, a nurse-led minor injuries unit and
outpatient clinics as well as elective surgery and diagnostics.
The primary-care led TCs include a centre on the site of the Chase Community
Hospital in Bordon, Hampshire, and a centre at Ilkeston Community Hospital
in Erewash PCT. The Chase Hospital TC offers preoperative assessment
for local patients having day surgery elsewhere, leg ulcer clinics, chronic
pain management and some diagnostic services. Ilkeston Hospital TC has
day case theatres and diagnostic services.
Newham PCT, in London, has a dermatology TC run by a GP with a specialist
interest in dermatology. Patients are referred to the centre by GPs who
want a second opinion but do not consider that hospital referral is necessary.
The change in name from “diagnostic and treatment centre” to “treatment
centre” does not indicate any change to the TC programme. Trusts
are expected to move diagnostic services into the centres although this
has not yet happened to any significant extent.
Experience to date
The Modernisation Agency reports that TCs have certainly been successful
in achieving their aim of reducing waiting lists. Other benefits are
also said to have occurred from innovative ways of working associated
with the TCs. For example, length of hospital stay for certain knee
surgery has reduced markedly by use of new care pathways and effective
discharge planning.
However, in late 2004 it was reported that some NHS TCs are in financial
difficulty because of insufficient patient referrals. One suggested explanation
is that patients may prefer to wait for local treatment rather than travel
(in some cases long distances) to receive earlier treatment in a TC.
In some places, it appears that GPs have been reluctant to make referrals
to the new centres. Another issue is that some PCTs might have run out
of money for new referrals for the current financial year.
Also, although across England there are still long waiting lists, it
has been suggested that there might now be too much capacity in some
areas.
The Ambulatory Care and Diagnostic Centre (ACAD) at Central Middlesex
Hospital, in West London, and Ravenscourt Park, the orthopaedic TC for
North West London — seen as flagship TCs — have both reported
excess capacity because of insufficient referrals. ISTCs
Many of the companies that have been awarded contracts to run the ISTCs
are not traditional UK private sector providers but are foreign-based
companies.
The current ISTCs, which have initial five-year contracts, are largely
surgical units although there is a mobile magnetic resonance imaging
unit. Procurement of further independent sector diagnostic facilities
is under way.
The first ISTC opened in Daventry in 2003, run by the Birkdale Clinic.
It is a modular build in the grounds of the Daventry and South Northants
PCT headquarters at Danetre Community Hospital. In its first year, the
TC concentrated on cataract surgery, and the PCT says that waiting times
in Northamptonshire were reduced from nine to three months.
The Government’s plans for ISTCs have proved controversial. Although
welcoming the extra capacity and the chance to shorten waiting lists,
the British Medical Association, the Royal College of Physicians and
the Royal College of Surgeons have all expressed reservations. These
include concern that the centres will “poach” NHS staff,
that moving uncomplicated surgery out of the acute hospitals will limit
training experience for surgeons and that the centres may impact on income
flow to local acute NHS hospitals. Another stated concern is that freestanding
ISTCs may not be able to cope with unexpected clinical problems.
The DoH response is that it is not possible to increase capacity in the
NHS fast enough to meet waiting list targets and that the independent
sector units are being approved where there are bottlenecks and the NHS
does not have the capacity — in terms of premises, staff or management — to
deliver TCs.
Initially, the DoH emphasised that ISTCs would not be allowed to dilute
NHS staff resources and that all staff would be additional (and would
either come from overseas or would not have worked in the NHS in the
previous six months). This was apparently on the understanding that all
work in the ISTCs would be additional to NHS work. In the event, some
PCTs have transferred work from acute trusts into an ISTC, and in such
cases NHS staff are being allowed to transfer to the ISTCs under secondment
arrangements.
An illustration of the work patterns is given by the recent announcement
of five new ISTCs in the South East that plan to treat 16,000 patients
a year — around 6,000 procedures will be new activity while the
rest will transfer from the NHS, freeing local NHS facilities. Pharmacy services
What does the development of TCs mean for pharmacy? Pharmacy services,
in addition to supply, that are being provided by some of the early
centres include involvement in preoperative assessment clinics, development
of protocols for discharge medicines, ward-based pharmaceutical care,
setting up patient group directions (PGDs) and support to nursing staff
on medicine issues.
A key requirement of TCs, given the rapid patient throughput, is well-organised
and effective discharge planning. For pharmacy, this means that procedures
are needed to ensure that patients have the drugs they need by the time
they are ready to be discharged.
Since the work of a TC is carried out to defined care pathways, it can
be helpful for pharmacists to be part of the multidisciplinary team setting
up these systems to ensure that appropriate pharmaceutical input is included.
Much of the medicine supply, eg, postoperative antibiotics and analgesics,
is protocol-driven.
The current NHS TCs have adopted different models of pharmaceutical service
provision, depending on funding and staffing issues and on perceived
need. Some NHS TCs have had funding for pharmacy services. Others have
had no new money and services have had to fit around the existing workload.
As a result, some NHS TCs have their own pharmacy staff and offer a full
clinical pharmacy service while others are unable to offer more than
a medicines supply service to the TC, although pharmacy advice is always
available as required.
Although the aim is to select “uncomplicated” patients for
surgery in TCs, there are still medication issues to consider and pharmacy
involvement in TC preoperative assessment clinics has been instigated
in several centres. In these clinics, the pharmacist takes a medication
history, sorts out any medicine problems, arranges discharge medicines
and can advise on any medicines — prescription, OTC or complementary — that
need to be stopped before surgery.
In one NHS TC in which pharmacists were involved in the preassessment
clinics (funding for this has now ended), PGDs were used for discharge
medicines — mostly analgesics — which were supplied to the
ward in advance of the patient’s admission. In a few cases, the
discharge medicines were given to patients at the preassessment clinic,
although this did cause some problems with patients losing their medicines
by the time they were required.
Ravenscourt Park TC, a stand-alone TC in West London, has one full-time
pharmacist and an on-site dispensary. Agreement has recently been obtained
for the pharmacist to attend preassessment clinics. The pharmacist also
carries out ward-based prescription monitoring and medicines management.
Discharge medicines are dispensed in advance and kept in the patient’s
bedside locker. There is also funding for a technician at Ravenscourt
Park but this post is currently unfilled as there is insufficient work.
Another TC with funding to provide a clinical pharmacy service is the
Orpington NHS TC. This centre, which occupies one floor of the old Orpington
Hospital, has three wards, two of which (44 beds) are currently open
for orthopaedic and general surgery. A team of two pharmacists, two technicians
and one pharmacy assistant work full time on the TC and are involved
with patients from pre-assessment through to discharge. There is no dispensary
at the TC at present — one is currently being built — and
so medicines are obtained from the nearby acute hospital. The pharmacy
staff are currently looking to see if there is any opportunity for supplementary
prescribing in the unit.
Even with a high level of pharmacy service, it is unlikely that pharmacists
can see all patients because TCs can have long working hours and might,
for example, run weekend preassessment clinics. In several centres, pharmacists
have therefore been involved in training and in setting up protocols
to support nursing staff on medicine issues.
Much of the medicines supply in TCs involves use of prepacks and PGDs
for nurse supply. Medicines for which PGDs have been developed by pharmacists,
or are planned, include postoperative analgesics, laxatives, eye drops
and, in one endoscopy centre, Helicobacter pylori eradication regimens.
Some NHS TCs are physically linked to an acute NHS hospital; others are
some distance away, which can be an issue if there is no on-site pharmacist.
For example, medicines for the NHS TC at Kidderminster Hospital are supplied
from the pharmacy at the Alexandra Hospital in Redditch, around 20 miles
away. In this TC, medicines are provided as prepacks with PGD supply
by nurses, and on FP10HP prescriptions. Occasionally, prescriptions might
be faxed to the pharmacy.
The Central Middlesex Hospital ACAD is only a few hundred yards from
the main hospital. Medicine supply for the day surgery patients is again
largely via PGDs and prepacks, but a porter service is available to take
prescriptions to the main hospital pharmacy for items that the pharmacist
would want to check, such as paediatric ear, nose and throat medicines.
The current primary-care led NHS TCs have little day-to-day pharmacy
involvement although PCT pharmacists will be involved in policy on medicine
issues.
ISTCs have to be registered with the Healthcare Commission, which defines
national minimum standards. One of the commission’s guidelines
is that TCs should have pharmacy advice. At present, most of the ISTCs
do not have their own pharmacies but have contracted with an NHS supplier
for pharmacy services.
For some centres, this is an interim arrangement. For example, Care UK
Afrox Healthcare, a consortium of Care UK and Afrox Healthcare, a South
African company, has two interim ISTC sites for orthopaedic surgery,
at Ilkeston Hospital and Bassetlaw Hospital, where there are agreements
with the local trusts for pharmacy services. In June, the ISTC will move
to a new purpose built, freestanding site at Barlborough Links which
will have its own pharmacy. Pharmacy staff will be recruited for this
centre — like the medical and nursing staff, pharmacists must have
not worked in the NHS in the past six months. There are similar plans
for the company’s orthopaedic ISTC in Plymouth.
Two mobile ophthalmic ISTCs (for cataract surgery) are being run by Netcare
UK, another South African company. The units park in hospital sites and
pharmaceutical services are procured from the host hospital. Netcare
is also opening an ISTC in Trafford, Manchester, in 2005. This centre
is a new building on the Trafford General Hospital site and it will undertake
orthopaedic surgery, general surgery and ear, nose and throat surgery.
Pharmacy supply and support services will be provided by the hospital
pharmacy under a service level agreement.
For some of the other planned ISTCs, the provider has not yet decided
whether to provide an in-house pharmacy service or to contract a service
from the local trust. Conclusion
Treatment centres seem likely to become an established model for providing
routine elective surgery in England. They should provide a cost-effective
way of treating patients and have already had an impact on waiting
lists. Pharmacists need to be aware of this development when planning
their future services.
· Community pharmacists need to be prepared for this development as
they may be involved in dispensing treatments previously provided by
hospitals
· Hospital pharmacists need to have protocols in place to respond to
these new ways of working and have an adequate range of pre-packed medicines
· The need for adequate medication histories is crucial to prevent delays
in discharge — although hospital pharmacies may obtain these at
preadmission clinics, they need to liaise closely with their community
pharmacist colleagues
Early experience from the first TCs is of varying levels of pharmacy
involvement, from provision of a full clinical service to training of
nursing staff on medicine issues. Setting up new ways of medicine supply,
such as through PGDs, is also prominent. Since the TCs are designed for
rapid patient throughput, a key aspect for pharmacists will be in the
development of protocols for postoperative discharge regimens. The treatment
centre programme is one example of the evolving patient-centred systems
of health care for which all pharmacists will need to be prepared.
ACKNOWLEDGEMENTS Thanks are due to Ray Fitzpatrick and Alison Ewing,
chairman and member, respectively, of the Hospital Pharmacists Group
Committee.
References
1. Department of Health. NHS plan: a plan for investment, a plan for
reform. London: Stationery Office; 2000.
2. Department of Health. The NHS improvement plan: putting people at
the heart of public service. London: The Department; 2004.
3. Department of Health. Chief executive’s report to the NHS. London:
The Department; 2004. |
The
Pharmaceutical Journal