Since the start of 2017, we’ve been redesigning our system for clinical outcome letters at the Sussex MSK Partnership. A backlog of nearly 7,000 unsent letters (some of which had been in the system for up to seven months) has been reduced to less than 2,000 and the seven day target is now being met for onward referrals. We are working towards achieving this for other clinical outcomes such as discharges and follow ups.

Why the seven day commitment matters

The reason this is important is that we are a key service through which patients can access diagnostics and specialist advice.  Our Advanced Practitioners are able to request diagnostics such as MRIs which ordinarily other clinicians wouldn’t have access to.  They can also direct list for surgery and work alongside consultants in a community setting which significantly eases the stress of accessing hospital care for patients.  If we do not meet this timeframe for clinical outcome letters for patients who we are referring on elsewhere for treatment we delay patient care.

For those patients who are discharged from our service, these letters are important as they hold a record of how they can manage their condition and care at home, as well as tell the GP vital information about what help patients have received.

For all patients, these letters are an important part of the communication they have with their clinicians. In 2016 we made a decision to change our letters to better support patients.  We amended the templates so that they were addressed directly to the patient.  This also meant a big cultural change for our clinicians as they now direct their correspondence to patients and not their fellow clinicians. This enforces our ideology that information about patients should be owned by patients. We designed our letters with input from patients.

The growth of the service

When we were a smaller team with fewer patients to see, the seven day commitment was an easy one to keep.  When I first started working in the service in 2014, there were three or four people working in letters per day.  If the team developed a backlog then they would bring an extra person in for a week and that would solve the problem.  Except it didn’t really solve the problem, because we weren’t changing the system in anyway, we were just managing what was coming in with additional resources.

However over the last two years our service has grown significantly.  As our population grows, quick access to diagnostics and experts, close to home, becomes even more important because it makes sure people are seen in the right place at the right time by the right person.  Our letters team has grown from a handful of people to 12 people who process up to 250 letters a day.  We now operate across three CCG areas (Horsham and Mid-Sussex, Crawley and Brighton and Hove) and we are one of the biggest employers of Advanced Practitioners in the country.

A manual counting system

Our letters system remained unchanged during the earlier phase of this rapid growth. People continued planning their work by manually counting (250) appointments a day.  At times there were more than 7,000 patients waiting for information after their appointment. The information in a letter is critical as it allows the patient to own their care and engage with GPs and other clinicians about what they need in the next stage of their journey.

By the time we had finished counting everything manually, we would have to start again because we would be three days out of date.  In a world of booming technology, some commentators see the NHS as a lumbering leviathan still chipping away at paper and stone tablets.  I don’t actually think that is fair because the NHS collects an extraordinary amount of data from people.  But sometimes there is a struggle to find the relevant data and using it to make service decisions and improvements.  We needed to know what was happening to whom and when.  What was causing unnecessary delays? And how could we keep patients as safe as possible, knowing that there were going to be delays for up to three months while we worked through this enormous backlog?

Solving the backlog by redesigning the system

Facing these delays we made a couple of key decisions:

  • No matter how big the backlog gets we do not let our urgent letters fall outside of 24 hours. Everyone in the team knows that this is where the biggest risk lies because here is where you find conditions which are time sensitive, such as Cauda Equina.
  • We don’t just throw resource at the problem in order to fix it. Sending a good quality clinical outcome letter takes skill and time to learn.   To be able to respond to every type of situation that the system throws at you even more so.  Desperation leads us to a place of ‘we just need more bums on seats’.  The problem with this is that quickly the model becomes unsustainable and even dangerous as people operate in a place of having a large, newly skilled team who are not supported to do well.

As a service we have found looking at the wider system for answers was key to solving this backlog.

  • We make sure that our reporting and planning works for us.  Whereas before we were manually counting at 8am every morning, now I push a couple of buttons and I get a more accurate account of what is in the system than has ever been possible.  We have done this this by adopting a recall system, which has traditionally been used by diagnostics very successfully.  It has meant we didn’t need to look at other more expensive technological solutions.  When a clinician fills in their clinical template a recall is automatically generated in the background.  Using the reporting tools we already had set up for the service we can now gather this data in one place and begin to analyse it more effectively.  We can now match our capacity to what is needed meaning when we identify a problem we can tell the whole story.
  • We can ask for the help we need.  Now that we can use the data we have to tell a clearer story, we can talk to other teams and explain what we need.  Faced with a clear question, others are better able to respond to us in a way that actually does help.  We have also managed to reduce the amount of human error that occurs when manually counting.
  • We learn from our mistakes.  There have been some painful lessons along the way but with the amazing support from a caring team I am proud of how we have continued to learn throughout.  During this journey relationships have been damaged as we failed to deliver what we promised.  Trust between ourselves and patients, Commissioners, partners and colleagues has been lost as we worked to change the system.  It is only by remembering that broken systems – not people – cause failure that I have been able to be more understanding of the mistakes I have made, and I hope in time these relationships will be stronger for that learning.

As I write this we have 1,899 letters in the system.  Our target is 1,750.  We have raised the percentage of letters we are sending within seven days from 30% to 60%.  However more important than the numbers is the fact that any patient who needs to be seen within secondary care or by another provider is receiving their referral within seven days.  Every day that goes past we get closer to being able to send patients’ discharge and follow up letters within 7 days, and we expect to achieve this in September. We have tested the processes we have and we are continuing to make improvements that mean we will be able to continue to meet demand as it rises and still give patients letters that are for them, and to them, not just about them.

Find out more

Our new letter templates include signposting services which support general health. To find out more about those services in your local area visit the Sussex MSK Partnership website.

tagged in Sussex MSK Partnership Central, systems thinking

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