Vaughan Gething AM, Deputy Minister for Health
The National Planned Care Programme has been created to help NHS Wales to deliver sustainable services. We need to re-design services that are unambiguously focused on quality and improving patient outcomes and experience. That means delivering a service that balances capacity and demand whilst being grounded in the best available clinical evidence.
Since its development in 2014, this clinically-led programme has focused on 4 areas – ophthalmology, orthopaedics, ENT (ears, nose and throat) and urology. These are 4 busy clinical specialties where we know that more can be done to reform the way care is provided – both in local communities and in hospitals – based on prudent healthcare principles.
Plans have been developed for each of these 4 specialties, which aim to improve patient experience and deliver sustainable services by 2020. They will do this by ensuring that NHS Wales cares for those with the greatest needs first, carrying out the minimum appropriate interventions, while focusing on a smaller number of areas with greater impact and outcomes.
Following the appointment of the programme’s clinical lead – Peter Lewis – and the specialty board chairs, the ophthalmology, orthopedic and ENT implementation plans have been published; the urology implementation plan was published on 14 March 2016.
The plans encourage clinicians in each of the 4 specialties to stop doing some procedures that are not benefitting patients – these are known as do not dos. This is in line with the prudent healthcare principle of only doing what is needed and to do no harm. The plans will ensure that health boards do not undertake procedures which the National Institute for Health and Care Excellence (NICE) has advised should not be undertaken – these are known as interventions not normally undertaken.
For example, the ENT plan requires compliance with national guidance on tonsillectomy thresholds, which is based on the number of tonsillitis episodes. The urology plan includes a change to the guidelines for patients with low and medium-risk bladder cancer undergoing cystoscopy, which will reduce the number of unnecessary treatments being carried out.
Lifestyle factors can have a negative impact on the results of some routine operations. Smoking, for example, is known to affect the outcomes of some foot and ankle procedures and many studies have shown rates of post-operative complications and length of stay are higher in patients who smoke or who are overweight.
As part of the plans, people who smoke or have a body mass index of 35 or more and are being considered for surgery will be referred for smoking cessation support and weight reduction management before their operation. Health boards will be required to provide a suitable range of stop-smoking and weight reduction support services and appropriate referral mechanisms for their patients.
Wherever possible the plans aim to make the most appropriate use of primary care services, while optimising patient experience. New measures will be put in place to ensure the right patients are managed in doctor-led hospital services, while the vast majority of patients will be seen in community-based services. For example, health boards will set up new community-based audiology services which are capable of managing direct referrals from primary care for hearing loss, tinnitus and vertigo or dizziness.
Ophthalmic diagnostic treatment centres have been established, which will enable clinics and services currently carried out in hospitals to be moved into local communities. These centres, which will reduce demand on hospital services, reduce delayed follow ups and ensure people are treated in a timely way, will be supported by a multi-disciplinary team made up of ophthalmologists, nurse practitioners and optometrists.
The plans aim, wherever possible, to reduce variation across Wales. We know that currently in orthopaedics, there is variation in the number of follow-up appointments that are offered following surgery. Health boards will now be expected to commission one surgical follow-up appointment after routine hip and knee replacement surgery between 6 weeks and 3 months after an operation unless there are exceptional circumstances. This is accepted practice in other UK health services. Ongoing outpatient review after this should not be routinely offered.
Across all the plans, there is a commitment that follow-up appointments should only be given where absolutely necessary, freeing up doctors’ time to treat more patients. Where a follow-up outpatient appointment is needed, clinicians will increasingly use technology to carry out virtual appointments wherever it is safe and appropriate to do so.
Collaborative care groups – between hospitals, community and primary care – will be established to empower people to manage their own health and patient experience and outcomes will be captured through the use of patient-reported experience measure (PREMs) and patient reported outcome measure (PROMs) questionnaires, which have been developed in each of the specialties. These will be introduced across health boards later this year. A key aspect of the plan will be to develop PROMs – this will allow health boards to understand and report on patient outcomes following surgery.
At present there is no standard way to understand how effective NHS interventions have been in these 4 areas and whether outcomes are in line with patients’ expectations. The development and implementation of these new PROMS and PREMS will also allow Welsh hospitals to compare themselves against other hospitals.
The Planned Care Programme is working with health boards and supporting them to implementing the actions for improved patient outcomes within each of the specialty plans. In doing this, it is sharing best practice across both health boards and specialities ensuring that all changes are fully embedded and sustainable. This reinforces our commitment that quality will remain at the heart of NHS Wales now and in the future.