1. A PRACTICAL EXAMPLE OF DCAQ Dr Gerry Beattie Clinical Lead, NHS Lothian 18 th November, 2009

2. DCAQ Gynaecology - background Why is the out-patient waiting time 16-18 weeks ? Why is the out-patient waiting time 16-18 weeks ? What are the consultant staff doing ? What are the consultant staff doing ? Why are we losing capacity and how can we stop it ? Why are we losing capacity and how can we stop it ? What are we going to do about the next round of job planning ? What are we going to do about the next round of job planning ?

3. DCAQ Gynaecology UNDELIVIERED ACTIVITY – the waiting list, service entry points, primary care interface. UNDELIVIERED ACTIVITY – the waiting list, service entry points, primary care interface. DELIVERED ACTIVITY – productivity, rotas, inappropriate activity, templates. DELIVERED ACTIVITY – productivity, rotas, inappropriate activity, templates. LOST CAPACITY – leave, compensatory rest, short notice cancellations LOST CAPACITY – leave, compensatory rest, short notice cancellations

4. DCAQ Gynaecology DEMAND DEMAND CAPACITY CAPACITY ACTIVITY ACTIVITY QUEUES QUEUES

5. Two important points to remember It’s just good housekeeping, it’s not rocket science ! It’s just good housekeeping, it’s not rocket science ! Just because ‘it’s aye been done this way’ doesn’t mean there isn’t a better way of doing it ! Just because ‘it’s aye been done this way’ doesn’t mean there isn’t a better way of doing it !

6. Demand – the problems Unclear as to what the demand was in terms of numbers Unclear as to what the demand was in terms of numbers No idea as to the case mix out there No idea as to the case mix out there 6 entry points into the system – NRIE, WGH, SJH, LCTC, Roodlands, Liberton. 6 entry points into the system – NRIE, WGH, SJH, LCTC, Roodlands, Liberton. Little dialogue between primary care and the acute sector Little dialogue between primary care and the acute sector

7. Demand – some solutions Centralised Booking set up for Lothian – bringing all referrals to one central point in the NRIE and now moving to e referral and e-triage Centralised Booking set up for Lothian – bringing all referrals to one central point in the NRIE and now moving to e referral and e-triage Outcoming from triage recorded to inform the size and location of service queues and what needs to be in place where Outcoming from triage recorded to inform the size and location of service queues and what needs to be in place where Exploring electronic GP helplines to prevent patients becoming referrals Exploring electronic GP helplines to prevent patients becoming referrals

8. Another important point - Demand is not a given, it can be influenced in your favour Demand is not a given, it can be influenced in your favour The 3 D’s – Driving Down Demand ! The 3 D’s – Driving Down Demand !

9. A thought - What if referrals were not referrals and simply requests for advice ? What if referrals were not referrals and simply requests for advice ?

10. Capacity – the problems Difficult to define Difficult to define Difficult to measure Difficult to measure Lost capacity Lost capacity Reliant on Consultant job plans Reliant on Consultant job plans

11. What is capacity ? Templated capacity (52 weeks) Templated capacity (52 weeks) Adjusted capacity (42 weeks) Adjusted capacity (42 weeks) Delivered capacity (about 36 weeks) Delivered capacity (about 36 weeks)

12. What is capacity ? Capacity is a dynamic concept that is constantly changing Capacity is a dynamic concept that is constantly changing It is not a straight line or a box with rigid sides It is not a straight line or a box with rigid sides

13. Capacity Modelling Real time job plans can help measure capacity Real time job plans can help measure capacity Convert weekly job plans into at least 4 weekly spreadsheets to overview capacity and identify peaks and troughs Convert weekly job plans into at least 4 weekly spreadsheets to overview capacity and identify peaks and troughs A real need for dynamic prospective capacity modelling A real need for dynamic prospective capacity modelling

14. Capacity – some solutions Centralised booking has allowed capacity measurement across Lothian and respond to service pressures Centralised booking has allowed capacity measurement across Lothian and respond to service pressures Real time job plan mapping Real time job plan mapping Sanitisation of clinic templates Sanitisation of clinic templates Standardisation of clinic templates Standardisation of clinic templates Flexibility of consultant workforce Flexibility of consultant workforce

15. Activity – the problems Lots of it –but not accurately recorded Lots of it –but not accurately recorded Coding issues Coding issues Inappropriate activity Inappropriate activity Clinic templates – new/return ratios Clinic templates – new/return ratios Outreach clinics Outreach clinics Consultant productivity Consultant productivity Role of senior trainees Role of senior trainees

16. Activity – some solutions Accurate recording and coding, with medical input into coding Accurate recording and coding, with medical input into coding Minimum standards for clinic templates Minimum standards for clinic templates New/return ratios revised in the light of speciality development New/return ratios revised in the light of speciality development The ring pessary challenge The ring pessary challenge Utilisation of senior trainees Utilisation of senior trainees Keep the mavericks in the building Keep the mavericks in the building

17. Queues – the problems There was a big one and lots of little ones There was a big one and lots of little ones There was no idea of how wide the pathway had to be to accommodate the queues There was no idea of how wide the pathway had to be to accommodate the queues Chaos reigned ! Chaos reigned !

18. Queues – some solutions Centralised booking has streamlined, quantified and reduced the queues Centralised booking has streamlined, quantified and reduced the queues Patients now seen by the most appropriate clinician at the most appropriate site Patients now seen by the most appropriate clinician at the most appropriate site Waiting time across Lothian now 6 weeks and falling ! Waiting time across Lothian now 6 weeks and falling !

19. Question - DCAQ – where did we start ? Question - DCAQ – where did we start ? Answer - Job planning Answer - Job planning

20. The 2004 Consultant Contract Full time commitment of 10 programmed activities (PAs) per week – 4 hour sessions Full time commitment of 10 programmed activities (PAs) per week – 4 hour sessions Direct clinical care (DCC), Supporting professional activities (SPA), additional/external duties Direct clinical care (DCC), Supporting professional activities (SPA), additional/external duties 7.5 PAs DCC / 2.5 PAs SPA (Plans for 9+1) 7.5 PAs DCC / 2.5 PAs SPA (Plans for 9+1) Flexibility depending on commitments eg Clinical Governance leads etc Flexibility depending on commitments eg Clinical Governance leads etc EPAs – separate contract, no obligation EPAs – separate contract, no obligation

21. Job Planning The process is individual but collectively job plans must reflect the over all needs of the service The process is individual but collectively job plans must reflect the over all needs of the service Provides the capacity to meet the demand on the service Provides the capacity to meet the demand on the service

22. Job planning – the issues Plan the service to meet the demand Plan the service to meet the demand Consultant productivity – 42 wks – if not, why not ? Consultant productivity – 42 wks – if not, why not ? Notify, control, monitor and restrict leave – and learn to say NO ! Notify, control, monitor and restrict leave – and learn to say NO ! Get service into PAs and use EPAs for reward – eg cross cover / additional activity Get service into PAs and use EPAs for reward – eg cross cover / additional activity

23. Job planning – the issues Rota management to reduce impact of compensatory rest – lost capacity Rota management to reduce impact of compensatory rest – lost capacity Allow flexibility in the job planning process Allow flexibility in the job planning process Play to individual strengths Play to individual strengths Need all consultants look the same ? Need all consultants look the same ?

24. Consultant engagement Protected time gives recognition to the importance of the work Protected time gives recognition to the importance of the work Sell the carrot, not the stick Sell the carrot, not the stick Get one of their own doing the work Get one of their own doing the work

25. A disease analogy Symptoms of reluctance to change, reluctance to engage and inefficiency Symptoms of reluctance to change, reluctance to engage and inefficiency Syndrome of ‘ we’ve aye done it this way’ Syndrome of ‘ we’ve aye done it this way’

26. The challenge - Physicians of the utmost fame Were called at once, but when they came They muttered as they took their fees There is no cure for this disease Hilaire Belloc

27. Any questions ? Any questions ?