How referral to treatment performance can improve timely access to hospital care
I’ve just returned from a lightning study tour of England and Scotland with the Victorian Healthcare Association (VHA). We spent time with a range of English and Scottish National Health Service (NHS) organisations – hospitals, ambulance services, commissioners, mental health providers, community health services, general practitioners and quality agencies.
I learnt loads, but the single most impressive thing I learnt that I believe could significantly improve the provision of healthcare here was ‘Referral to Treatment’ times. Referral to Treatment (RTT) is a NHS time performance indicator that covers the entire patient journey from the initial referral by a person’s general practitioner to a consultant led service at a public hospital to the start of treatment, including for the first time treatment undertaken in an outpatient setting. There are a suite of rules and definitions for ensuring the waiting-time clock starts and stops fairly and consistently, reporting and transparency.
The RTT is 18 weeks. It’s 62 days for cancer.
This means that if I have a patient who requires cataract surgery it’s a maximum of 18 weeks from the time the referral is received by the hospital until surgery is undertaken. If I refer a patient with severe knee osteoarthritis and the surgeon feels they need a knee operation, then it’s a maximum of 18 weeks from receipt of my referral to the operation. If they feel the patient needs physiotherapy, it’s a maximum of 18 weeks until receipt of my referral until physiotherapy starts. If the physiotherapist refers them back to the surgeon as an operation is required, the 18 week clock starts again from the physiotherapy referral until the operation. For a woman with breast cancer it’s 62 days from receipt of referral to her first definitive treatment (e.g. surgery).
For those that don’t know how our system currently works, it is:
- GP refers a patient to a public hospital service specialist outpatient service.
- According to Victorian Department of Health and Human Services (DHHS) requirements, both the patient and GP receive notification of acceptance (or not) within three days. In my experience, this notification rarely comes with an appointment date.
- The patient is triaged and usually placed on a waiting list for the specialist outpatient service required. The wait for the appointment can be from weeks to years – depending on the need as a result of triage, hospital and service. For a patient and GP, there is no real time waiting list to let you know how long this will be.
- The patient receives notification of their appointment. (DHHS does not require GPs to be notified – some hospitals and departments notify GPs, some don’t.)
- The patient is seen in outpatients.
- If a person is placed on an elective surgical waitlist, there are expectations of timeliness according to need, with expectations that Category 1 is within 30 days; Category 2 within 90 days; and Category 3 within 12 months. The patient’s surgeon decides the appropriate triage category for the patient.
We therefore have a robust and transparent expectation and measure from being placed on surgical waitlist to surgery. I also understand that the DHHS and hospitals are undertaking a series of strategies and lots of work in addressing specialist outpatient service access and flow, however the performance of hospitals and services within a hospital is not currently readily available to GPs or patients.
Our current system drives the following behaviours and problems:
- Patients being referred to several hospitals for the same problem as GPs don’t know where the person will first be seen.
- Patients who can ill afford it are referred to private specialists and services with out of pocket expenses as GPs know they can be seen in a timely way.
- For complex patients, deteriorating situations and long waiting times there are often several contacts by GPs and patients to hospitals in trying to understand the wait time, expedite an appointment or make management decisions.
- Quality of care issues. Access to appropriate care in a timely way is a fundamental component of quality and safety. In the current system, none of us know when a patient will be seen and treatment will start in an outpatient setting. It is not a public expectation of performance, it is not publicly available, and therefore GPs and patients cannot make informed clinical, referral and treatment decisions.
- The potential for “hidden waitlists” for access to the first specialist outpatient service and conceivably to go onto the surgical waitlist.
- Specialist outpatient inefficiencies e.g. there are few current incentives to discharge patients not requiring specialist care to primary care to free up appointments for new patients, nor to decant services not required to be undertaken by hospitals to community care.
You might be thinking, ‘we couldn’t possibly move to an RTT of 18 weeks’, but let me debunk some potential concerns:
- We don’t spend enough money on health
Australia spends about 10% of its GDP on health; the UK spends about 8.8%.
- Too many people use our public hospitals
We have a private insurance rate of about 45% with about 40% of our separations in private hospitals. The UK has much lower levels of private hospital care, with about 10% of the population having private health insurance and a much smaller private hospital system.
- They can’t possibly meet these 18 week timelines
There is an NHS target of 92% meeting RTT. The NHS met this target every month since its inception in April 2007 until December 2015, when performance was 91.8%. As of January 2017 performance had dropped slightly to 89.9%.
- The quality of their healthcare system must be less
A 2017 study of 11 different national healthcare models, by researchers at the New York-based Commonwealth Fund ranked Australia's mixed public-private system second best. The United Kingdom's NHS came out as the best system overall.
- We don’t measure the journey from receiving a referral to being seen, and being seen to first treatment.
Agreed, but we could start.
RTT was introduced in 2007. It was politically set and driven. Hospitals did not put their hands up for it and those that I heard from told me the first few years were hard for hospitals – with lots of extra resourcing, performance management and system redesign required. They also told me it had fundamentally and seismically improved timely access to public hospital non-acute care.
Now, don’t get me wrong, I think we have a fantastic system and much better building blocks than the UK. Interestingly I think this is borne out in the US study I referred to – for despite the RTT, we have better access than the UK (perhaps due to our primary care system and public-private mix), administrative efficiency and healthcare outcomes.
So let’s make a good system even better. Let’s adopt a clinically relevant measure that supports accountability and transparency to timely non-acute care in the public hospital system. I’d like to see our governments commit to adopting an RTT by 2020, and with our healthcare services, start working towards it now.
It has the potential to change my life as a GP, but more importantly change the lives of my many patients who are waiting for hospital outpatient appointments and treatment.
Dr Ines Rio
Section of GP
This article appears in the October/November 2017 edition of Vicdoc.
References available from the Editor on request.