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Discussion: Rotherham NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust on their approach to waitlist validation

We were joined by James Rawlinson, CIO at South Yorkshire and Bassetlaw ICS and Director of Informatics at The Rotherham NHS Foundation Trust, along with Helen Williams, Transformation Lead at Royal Cornwall Hospitals NHS Trust, for a live panel discussion on their approach to validating their waiting lists.

On projects and work around waitlist validation

Helen: Historically, we’ve done various waiting list validations that have been coordinated by the access team; they’ve been incredibly administratively heavy in terms of sending out letters and so on. But last year we implemented the Patient Hub, which is provided by Netcall and has a waiting list validation module. In October 2022 we embarked on our first specialities to go out via the Hub, to check that patients on our new outpatient waiting list and had waited past the 40 weeks stage still required that appointment.

To date, we’ve targeted three specialities – neurology, orthopaedics and cardiology at that 40 week stage. We did try neurology at over 52 weeks as a test to see how that would work.

We could design the responses for the patients so we’ve kept it as simple as possible. We ask if they still want the appointment, yes or no, and also ask if they would consider travelling out of their county, to try and capture those patients who would consider this and flag it as an opportunity if it becomes available. Patients can state that they no longer want the appointment because either symptoms have been resolved or they have been seen elsewhere, and the final option is that they can tell us if they want to speak to somebody. That triggers the system to tell the team to contact the patient to discuss that in more detail with them.

James: Back in August, like everybody, we recognised that we have a large waiting list that is getting bigger and bigger and validation teams that we’re asking to work even harder. So we got together with our strategy and planning team, and our service managers, and started to think about mapping a solution out.

We had some ability in house and we worked closely with our local children’s hospital in Sheffield, particularly looking at follow-up patients and targeting our neurology and dermatology patient lists at the 40 week mark. We use text messaging, because we didn’t have the capability to stand up electronic forms really quickly and we wanted to get something up and running pretty fast. So our development team used some of the tools that we already have and customised text messages for those cohorts.

We did get interesting differences in responses. We thought we would get more patients from dermatology telling us that they no longer require treatment, but actually it was the other way round and we got a higher response rate from neurology. We also noted that the majority of responses, whether they were saying yes or no, happened very fast, probably within the first hour of sending all the messages out. Over time it trailed off.

I’d say about 40 percent of the people contacted didn’t reply at all, so there’s something to be explored there in terms of why that is – for example, do we have incorrect phone numbers or is there another issue?

By and large, it was generally well received. We did get people replying to us with other comments outside of our question, but that’s probably human nature – I can understand it if you’ve been waiting for a really long time and the organisation contacts you asking if you still want the treatment.

Removal rates between specialties 

Helen: The bottom line for those three specialties has been that an average of seven percent of patients have been removed from the waiting lists. Our highest response rate was from orthopaedics where we had nine percent of patients removed, then it went to neurology with seven percent and six percent for cardiology.

It’s successful in terms of actually being able to target the patients who no longer require treatment. Obviously, it’s important to let the referrer know that that’s the case, and close that loop so that there is confirmation that the patient has decided to come off the waiting list.

In terms of response rates, rather like James’s experience, we saw a very quick response. We had 63 percent of patients come back and confirm that they wish to proceed. Our rate for no response was quite low, though we didn’t have contact details for all so it’s reliant on us having mobile numbers and email addresses within the system, and consent to use them too. We did a pragmatic activity when we implemented the portal around implied consent so that people who had listed mobile numbers knew to actually flag that they consented to being contacted. But we know that there are some people that will have missed this.

I’d say we actually had a higher response rate than we would have done if we had actually sent out the paper versions. Like James said, we were also surprised by the speed of the turnaround.

On challenges 

Helen: When we’ve done it before, we’ve gone out in defined batches and specialties, and it’s been managed quite tightly. But it’s always been an additional task that sits within the access team. Now we’ve got all specialities going out later this week to target everyone on the over 40 week lists and it will be a rolling feed, so as soon as a patient reaches 40 weeks, it’ll just continue. So I think the challenge is managing all the outputs and ensuring that everything is updated, that we’re removing people who can be discharged in a timely manner so they don’t inadvertently get given appointments they don’t need.

At the moment, there’s not a link from the portal into PAS, so updating information for all of the patients who have been validated is a manual process. We are working on getting an auto-update process in place, but it’s a challenge – one that the team have risen to really effectively in terms of keeping on top of things. At the moment, we’re just looking at new outpatients, so as we expand the volume will be quite extensive so we need to look at how we proceed.

I think the other challenge is around offering patients an opportunity to speak to someone. There can be a variety of queries and some of them potentially need clinical input. A patient might not understand fully whether they still need that appointment or not, and they need someone with clinical capacity to answer that question. Clinicians are already up against it in terms of trying to clear the backlogs, so this is another ask on top of their existing workload.

James: The very first time we tested this, we said we would focus on patients on the over 50 week lists. We were ready to go live but shortly beforehand we did our own data quality validation just to check. We found that our booking centre had actually already booked appointments for the list we were about to go live with. They work in chronological order, so those who had been waiting the longest had already been offered appointments. So we changed the algorithm so that the people who had waited the longest wouldn’t get that wording asking them if they wanted to stay on the waiting list, because we knew the booking centre had probably already contacted them with the opportunity to book themselves in. So we learned that it was important to think about how that production line worked. It goes back to integration with internal and local systems.

We took the decision that, if any patient said no, they didn’t want to be on the list, a clinician had to validate it. That’s probably not scalable, realistically. So what we’re doing across South Yorkshire is lining up all our processes collectively as a single ICS, so that we are sharing the same approach and sharing what’s happening. If a patient says no, that information is integrated into their local EPR. Service managers would then go through that information when we got it back and discharge people, to minimise risk from a clinical safety perspective.

As I said, we did this via a text messaging solution. So there’s a question there in terms of whether it’s appropriate going forward when there are lots of members of the public who don’t necessarily have smartphones or won’t interact in this way. So going forward, we’re trying to figure out how we can start to combine methodologies, if we need to – if the evidence across our ICS and beyond suggests that we should.

Frequency of messaging

Helen: We’ve just completed the testing for the live feed to come through, so as soon as patients that are unbooked hit the 40-week threshold, that message will go out on a rolling basis. As James mentioned, it’s about getting ahead because it’s a movable beast. We’ve opted to download the contact data and then send the message straight out, with the recognition that some patients may also receive their appointment message just because that mechanism continues. So that number should be smaller in terms of batches, but continuous as the waits roll on.

James: We do manual batch processing, so we get the data from the EPR or PAS, looking within those parameters for patients who aren’t right at the top of the list with the shortest waits or right at the bottom with the longest waits, and manually send the text. But we want to be really efficient around that and automate the data to send the text continuously, seven days a week. What automation can do is make bad processes work really fast, so we’re making sure our process is really good before we automate.

Digital exclusion 

Helen: This is something that we’re monitoring really closely with the portal. We’re doing regular checks around the protected characteristics to test our reach and check that we’re not excluding any patients. We’ve done quite a bit with age, to see what take-up looks like across the age groups; it’s not surprising but it’s encouraging to see that engagement for the over 80s age group is still at 55 percent.

Looking at deprivation data along with the protected characteristics is a piece of work that is ongoing. That’s part of our next step.

From a Patient Hub perspective, there are defaults in place so that it just reverts back to paper correspondence for patients who don’t have the technology or choose not to utilise it.

For those patients that don’t respond or for the ones we might not have contact details for, we’ve taken a bit of a pragmatic view and for the sake of resources we’re not proactively doing something different – if they don’t engage, we’re not following it up with paper correspondence. This is a view we may change this view over time, but right now it’s just something we are keeping tabs on.

The role of the communications team with regards to patient and staff awareness 

Helen: We’ve done various simple things like have posters and banners around the organisations, both for staff and patient interest.

When we went into COVID, we developed a local patient information leaflet about the pandemic that was going out with all appointment letters. There was also the ‘I’ve arrived’ functionality which is an electronic management of footfall within the outpatient department.

So we’ve piggybacked onto that approach and on those correspondence methods to let patients know what’s happening, and to introduce patients to the Patient Hub.

From a staff perspective, we’ve been dealing with all of the specialties as the solution has been implemented to let them know that it is going live and make sure that we are filtering through to administrative staff. We’ve done briefing sessions and training with all staff, and we’ve used social media feeds to update them too. We’ve tried to provide some good news stories about going electronic. I’ve also just drafted some up-to-date comms for GP practices as well, because obviously we need to make them aware that the Hub is there, so if they get enquiries from patients they can answer them.

James: Our work was similar – we had a media campaign blitz early on. We added content to our website so that we could guide people through our FAQs and got the news out on our social media platforms.

If people don’t look at their correspondence online, then in a day or so the system will automatically send out a paper copy in the post. We’ve added our information onto those forms of correspondence too. So for those who don’t interact with us, we can at least try to raise some awareness in this way.

We’ve also added this solution into other interactions with patients, for example all the patient portals in the area. It’s a bit like when you book a flight; you can use Google or other platforms, but you’re looking at the same bit of information about the same plane and time. So we’ve focused on knitting information together across the patient digital ecosystem. Even though patients might interact with us in different ways, they’re looking at the same information.

Future opportunities 

James: It’s about scaling now. We also want to look at sharing approaches and methodologies across the ICS. If you’re a member of the public living within our ICS area, you might get different organisations contacting you, but if we’re all following the same wording and processes that will help to strengthen that single NHS message.

We’ve got lots of people using different platforms such as the NHS App, so in the future I’d want to look at how to leverage some of that national capability. That would mean that members of the public can use the tool that they’re used to, whatever it is.

Lastly, there’s work to be done around contacting those members of the public who don’t necessarily have smartphones and finding the best ways to contact them for waitlist management.

Helen: As I mentioned before, we’ll be automating this system, but the next steps will be targeting our inpatient waiting list. That will be slightly more complex, perhaps less automated, because our PAS has a lot of background factors in terms of measuring the waiting time from an elective perspective.

Just to echo James, there’ll also be work on keeping tabs on those patients who aren’t being reached yet. Do we target, how do we best target? Underpinning that is the continual need for education for staff to make sure that we’ve got mobile and email addresses that are collected on the system.

Our system vision is that the main port of call for all correspondence will be through the portal, and hopefully professionals will be able to have two-way conversations with patients within that. Certainly, it will be our key platform for communications.

Unexpected benefits

Helen: There has been enthusiasm from the specialties to support this initiative, albeit with concerns about the need for clinical input. In terms of benefits I didn’t expect, I think the response rate was probably the biggest surprise – both patients coming back and the speed at which they came back. It helped with enthusiasm; I think previous validation exercises have proved to be quite slow-burn with a trickle of feedback, but being able to see progress and monitor it electronically feels very dynamic. It helps teams embrace new ways of working and it has been very encouraging.

Many thanks to Helen and James for joining us and sharing their thoughts; the discussion can be viewed in full below.