Rheumatology Advance Access originally published online on May 10, 2007
Rheumatology 2007 46(7):1200-1206; doi:10.1093/rheumatology/kem125
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Provisional guidelines for applying the Department of Health (England) 18-week-patient pathway to specialist rheumatology care
1Honorary Consultant Rheumatologist, King's Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Mansfield Road, Sutton-in-Ashfield, NG17 4JL/Associate Professor and Clinical Reader, University of Nottingham Clinical Sciences Building, City Hospital, Hucknall Road, Nottingham, NG5 1PB, 2Consultant Physician and Rheumatologist, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, NE96SX, 3Chief Executive, National Rheumatoid Arthritis Society, Unit B4 Westacott Business Centre, Westacott Way, Littlewick Green, Maidenhead, SL6 6AR, 4Consultant in Pain Medicine, Southampton University Hospitals NHS Trust. Pain Clinic, D Level Outpatient Centre, Royal South Hants Hospital, Southampton and 5Rheumatology Specialist Nurse, King's Mill Hospital, Sherwood Forest Hospitals NHS Trust, Mansfield Road, Sutton-in-Ashfield, NG17 4JL, UK.
Correspondence to: Dr. D. A. Walsh, Academic Rheumatology, University of Nottingham Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. E-mail: David.Walsh{at}nottingham.ac.uk
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Abstract |
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Top
Abstract
BackgroundObjectives. The Government Department of Health (England) has set a target that by 2008 patients on pathways that do or may involve medical or surgical consultant-led care should wait no longer than 18 weeks from referral to start of definitive treatment. Department of Health guidance must be interpreted and applied to patients with rheumatological problems.
Methods. Provisional guidelines have been prepared in collaboration between the British Society for Rheumatology, British Pain Society, Department of Health (England) and other key stakeholders.
Results. Definitive rheumatological treatment comprises a package of care rather than a single action. The care package usually requires input from a multidisciplinary team using several modalities in parallel. Actions within the care package that must be taken before treatment can be said to have started, are definitive actions. Definitive actions should be based on evidence of cost-effectiveness, tailored to the individual patient and offered irrespective of local availability or accessibility. They should be agreed between partners in the patient's care. This requires face-to-face consultation between the patient and a health care professional with appropriate expertise and knowledge. All definitive actions specified at the outset of management within specialist care must be initiated or removed by agreement from the patient's care package before the clock can be stopped in the 18-week-patient pathway.
Conclusions. Service redesign may be necessary in order to achieve an 18-week-patient pathway for all patients. A consistent and appropriate definition of clock-stops should ensure that patients will benefit from excellent rheumatology specialist care without unnecessary delay.
KEY WORDS: Guidelines, Patient-pathway, Integrated care, Plans, Health service
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Background |
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Escalating health care costs and increasing patient expectations have been approached differently by health care systems across the world. The United Kingdom (UK) National Health Service (NHS) prides itself on delivering quality health care, free at the point of delivery and efficiently funded through central Government. Health care provision within the UK has traditionally been delivered by general practitioners within primary care and specialist services within secondary care. The majority of health care is delivered within primary care, which also acts as a gatekeeper through which patients may access secondary care services. In recent years, Clinical Interface Services have blurred the boundaries between primary and secondary care, and increasing use of Independent Service Providers by NHS Trusts has augmented the flexibility of service provision. Patients often additionally depend on Social Care provided by local authorities, voluntary and private sectors outside the NHS.
Imbalance between resource and demand within the NHS has resulted in inappropriately long patient waits for many services. British Governments have addressed long waits by setting limits to the times that patients may wait between referral from primary care and their new patient appointment within secondary care. Similarly, targets have been set for waiting times from referral to treatment for patients with specific medical diagnoses of cancer and heart disease. The introduction of targets led to a marked shortening of waiting times in these areas. However, health care providers have been accused of diverting resources away from other important services, in order to meet these targets. There is also concern that patients have waited undesirably long periods before receiving treatments at follow up appointments or through hospital admissions, and for diagnostic investigations, even though their first appointment within secondary care may have occurred shortly after referral.
In order to further improve services for patients within the NHS and to address these criticisms, the Department of Health proposed in its NHS Improvement Plan an additional target that by 2008 patients on pathways that do or may involve medical or surgical consultant-led care should wait no longer than 18 weeks from referral to start of definitive treatment [1]. The expectation is that for most patients the referral to treatment time will be much less than 18 weeks, and, for many, this is already the case.
The principle that patients should receive excellent care without unnecessary delay should be applied to all health care, although the 18-week-patient pathway specifically sets a target for pathways that do or might involve medical or surgical consultant-led care. Waiting times for therapy and mental health services will only be addressed by the 18-week-patient pathway where they are consultant-led. It is not intended that the 18-week-patient pathway should address medical or surgical emergencies, which always require immediate treatment or hospital admission (for example, cauda equina syndrome and septic arthritis).
The Department of Health is actively engaged with the National Health Service and other partners in the development of processes that will permit the implementation of an 18-week-patient pathway. Detailed guidance is embedded within a series of Government publications, addressing how the 18-week-patient pathway should be applied throughout the National Health Service [1–4].
Responsibility for achieving the 18-week pathway for individual patients will rest with Commissioners, who should negotiate arrangements with other service providers to ensure that the target is met. It is their responsibility to ensure that quality is maintained within any commissioned care pathway, whilst providers must demonstrate that they can achieve agreed standards. It is important, therefore, that all partners in patient care contribute to the implementation of the proposed 18-week-patient pathway.
The 18-week target should further improve patient care, so long as adverse effects are carefully avoided on those aspects of care that are not covered by Government targets. Waiting times for essential treatments should not be hidden by excluding them from the pathway. Clock-stops in the 18-week-patient pathway must be valid indicators of the start of definitive treatment.
There may be disparate views between clinicians, managers, patients and Government on what constitutes ‘treatment’, determining when the clock stops in the 18-week-patient pathway. If the clock is stopped at the first therapeutic activity instigated by specialist care, very much shorter referral to treatment times could be calculated than if it were only stopped at treatment that completes optimal management or cure. Patients and primary care commissioners will be able to use referral to treatment time data to help them choose between different service providers. However, competition between service providers may encourage them to use treatment definitions that minimize reported times, rather than those that represent optimal management. National guidance should ensure that data from different providers describe comparable treatments, and that those treatments are based on best available evidence.
Rheumatology specialist care is consultant-led and will be subject to the 18 week target. General guidance from the Department of Health must be interpreted and applied to patients with rheumatological problems, and more specific guidance will ensure that clock-stops are defined consistently and appropriately. The British Society for Rheumatology has been working with key stakeholders to this end, and this document represents interim guidance to ensure that patients will continue to benefit from excellent rheumatology specialist care without unnecessary delay.
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The rheumatology care package (Box 1) |
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Patients typically present to Rheumatology departments with complex problems, often requiring multiple interventions provided concurrently from several partners in their care. The Department of Health (England) recently published a framework document establishing how musculoskeletal services should be provided, both now and in the future [5]. This Musculoskeletal Services Framework emphasizes the roles of multidisciplinary teams, the need for an integrated approach to diagnosis, treatment and care provision, and the holistic and ongoing nature of that care. Definitive treatment for someone presenting to rheumatology specialist services therefore comprises a package of care, rather than a single action.
Box 1. The rheumatology care package
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The Department of Health defines definitive treatment as an intervention intended to manage a patient's disease, condition or injury and avoid further intervention [4]. In this document, we use the term definitive actions to indicate key actions within the care package that should be used in determining clock-stops for the 18-week-patient pathway. Several definitive actions may be needed before the care package (i.e. definitive treatment) can be said to have been initiated.
The care package will usually comprise input from a variety of professionals using several modalities in parallel. For example, physiotherapy assessment may occur at the same time as a disease modifying agent is provided for a patient with early inflammatory arthritis. Both treatments are essential components of the care package. In some localities, there may be only a short wait for drug treatment, whilst in another locality the shortest wait may be for physiotherapy. It is essential that the clock is not stopped following the start of the first treatment within the care package, if this were then followed by a ‘hidden wait’ before another component of definitive treatment were eventually initiated. We believe, therefore, that initiation of the last definitive action within the care package should stop the clock.
Concurrent provision of multiple treatment modalities by a variety of professionals requires effective team working. This is best provided by a multidisciplinary team (MDT). A competent specialist rheumatology MDT should include, as a minimum, a rheumatologist currently on the Specialist Register for Rheumatology, plus a registered general nurse, plus a chartered physiotherapist, plus a senior occupational therapist. The rheumatology MDT should also enable patients to access a podiatrist, clinical psychologist and pharmacist, with close interaction between the MDT and these professions. Members of the rheumatology MDT representing each professional group must have completed specialist training in rheumatology, and must maintain continuing professional development in rheumatology as required by their respective professional body. The team members must meet together regularly, and maintain a consistent approach to patient care.
Current evidence strongly supports multidisciplinary pain management for chronic painful conditions, including neck and back pain. Multidisciplinary pain management includes psychological intervention using a biopsychosocial approach. The British Pain Society has published guidelines on the necessary and desirable components of a multidisciplinary pain management team in the context of pain management programmes [6]. The key element of psychological interventions within multidisciplinary pain management necessitates the involvement of a chartered clinical psychologist or a British Association of Behavioural and Cognitive Psychotherapy-registered cognitive behavioural therapist. In this context, psychological interventions are provided as a part of consultant-led specialist care, make essential contributions to the assessment process, and should be included as definitive actions within the care package.
Patients are instrumental in the design of their care package. Recent guidelines across the NHS recognize the importance of patient involvement in the management of their own health care needs. Department of Health guidance indicates that patients should receive copies of correspondence between specialist and referrer. This principle of sharing case-specific, written information with the patient has been extended within the Arthritis and Musculoskeletal Alliance Standards of Care as the sharing of written care plans with patients [7–9]. The written care plan should describe the contents of the care package, and the pathway through which the package will be delivered. A patient-centred approach is essential in developing the 18-week-patient pathway in rheumatology.
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Definitive actions |
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Definitive actions document what should be available to patients within 18 weeks from referral to specialist care. They will vary according to diagnosis and the clinical problem. Most patients will have at least one presenting diagnosis plus at least one problem.
Definitive actions should include, as appropriate, planned investigations and treatments that should modify symptoms, disability and the course of the underlying condition (disease modifying treatment). They should also include communication of specialist opinion to both the patient and the referrer. In all cases, definitive actions should include explanation and discussion with the patient, adequate to permit informed agreement of the care package.
Definitive actions may be the provision of a specific, named treatment or of a generic nature. For example, the commencement of a class of drug such as a disease modifying agent may be identified as a definitive action, even though the exact drug to be used may depend on baseline investigations, not available at the outset of specialist care.
A definitive action may be a discrete action, or commencement of an ongoing action. For example, initiation of watchful waiting or active monitoring, or provision of a mechanism that may be utilised in the future, such as how to access a telephone advice line or blood monitoring service, may each be documented as definitive actions.
Although the boundaries between assessment, preparation and treatment are often blurred in clinical practice, they may be defined artificially in order to document definitive actions within the 18-week-patient pathway. Patients considering participation in a multidisciplinary pain management programme for low back pain may variously derive therapeutic benefit from a medical assessment that includes a meaningful explanation of their symptoms and may find that a period of preparation will help them benefit from subsequent participation in a pain management programme. Assessment should not stop the clock if this would create an inappropriate (‘hidden’) wait for a Pain Management Programme, whereas patients should not be rushed through their pathway when this would impede therapeutic benefit.
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Examples of definitive actions |
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This list is not comprehensive and rheumatologists frequently contribute to the care of patients with diagnoses and problems not listed below.
Examples of diagnosis-specific definitive actions
Inflammatory arthritis
Including rheumatoid arthritis, seronegative arthritis, undifferentiated inflammatory arthritis.
A clear decision on whether to wait watchfully or commence disease modifying agent should be agreed between clinician and patient at diagnosis. In the latter case, commencement of first disease modifying agent and provision of an appropriate mechanism for active monitoring should be within the 18-week-period.
Definitive actions should include access to the rheumatology MDT.
Low back pain/neck pain
All patients should be assessed for medical and surgical red flags and for psychosocial yellow flags.
Where medical red flag signs are detected (e.g. night pain, weight loss), appropriate investigations should be completed and appropriate treatments commenced within the 18-week-period.
Definitive actions should include initiation of physiotherapy if not previously commenced. Definitive actions should include access to a multidisciplinary pain management team, especially if psychosocial yellow flags are present.
Connective tissue disease
Appropriate investigations should be completed and discussed with the patient, determining whether corticosteroids, immunosuppressant or anti-coagulant therapies are indicated. Such investigations may include further specialist opinion, tissue biopsy and/or specialist immunological and radiological investigation.
A clear decision on whether to wait watchfully or commence immunosuppressive therapy should be agreed between clinician and patient as early as possible. In the latter case, the first immunosuppressive agent should be commenced and an appropriate mechanism for active monitoring should be provided within the 18-week pathway.
Examples of problem-specific definitive actions
Pain
Adequate analgesia should always be provided, where pain is a clinical problem. Optimization of analgesic medications should be completed within 18 weeks of referral, even though this often may not eliminate pain. Oral, parenteral or local corticosteroid administration should be considered for inflammatory pain.
Appropriate, evidence-based non-pharmacological treatments for pain should be commenced within the 18-week-period. Definitive actions may include commencement of individual psychological interventions, and/or multidisciplinary pain management programme, transcutaneous nerve stimulation and acupuncture.
Functional limitation
Physiotherapy and/or Occupational Therapy assessment and, if appropriate, commencement of treatments.
Psychological distress
Psychological assessment and, if appropriate, commencement of treatments.
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Agreeing definitive actions with the patient (Box 2) |
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The Musculoskeletal Services Framework emphasizes the importance of integrated care pathways, which move from prevention and self-care through to hospital care. The 18-week-patient-pathway may be considered to be a small section of each integrated care pathway. It is important to identify which actions within those pathways constitute definitive actions for the patient. Definitive actions should be identified as all actions that should, both on clinical grounds and according to patient preference, be initiated within 18 weeks of referral.
| Box 2. Agreeing definitive actions with the patient Definitive Actions should be:
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Actions should be regarded as definitive for the purpose of defining the 18-week-patient-pathway only if they are not conditional upon failure of less intensive treatments. Conditional actions are common in Integrated Care Pathways. In pathways where less intensive treatments should be tried before more aggressive treatments, the initiation of the less intensive treatments should constitute definitive action [2]. For example, adding sulphasalazine and hydroxychloroquine may be envisaged in the event that a patient with rheumatoid arthritis did not respond to initial treatment with methotrexate. However, initiation of methotrexate, rather than subsequent medications, would be documented as definitive action.
Definitive actions should be based on evidence of cost-effectiveness. National guidelines, or, in their absence, local guidelines or integrated care pathways should determine what should be included as definitive actions. However, guidelines may not be available for all rheumatological problems, in which case definitive actions should reflect current best clinical practice as would be determined by a group of competent individuals. New national guidelines should be created to reduce the risk of inappropriate regional variation in care provision. The 18-week-patient-pathway should be determined irrespective of a patient's participation in research, except where the Research Ethics Committee has approved modification of the usual patient pathway as a part of the research.
Definitive actions should be tailored to the individual patient on the basis of clinical need and patient preference. Different patients will have different experiences prior to the point of referral to specialist care. Some may be newly presenting with their problem, whereas others may have already had consultations and a variety of treatments, some even in secondary care. Different patients, therefore, may enter integrated care pathways at different points. Furthermore, previous experiences, comorbidities and other ongoing life events each influence which actions patients wish to pursue within 18 weeks of referral.
Definitive actions should be offered irrespective of local availability or accessibility. They should be identified on the basis of clinical need, patient preference and best available evidence. Where there is good evidence that one treatment option is superior to another, and where that superior treatment is available to patients within the NHS as a whole, then the superior treatment must be offered as a definitive action. It would not be acceptable for less effective treatments to be offered alone because of lack of local resources or long waiting times for the more effective treatment. For example, if a patient fulfilled national eligibility criteria and wished to be treated with a biological agent for rheumatoid arthritis, then ‘provision of a biological agent’ would be specified as a definitive action. The patient should be informed about local difficulties in providing such an agent at the time.
Agreement of definitive actions with each patient requires face to face consultation with a health care professional with appropriate expertise and knowledge. This permits adequate discussion of the advantages and disadvantages of appropriate alternatives, and assessment of whether the patient's agreement is adequately informed. The health care professional(s) responsible for agreeing definitive actions should have adequate expertise and knowledge in all areas of appropriate diagnostic testing and treatments, in order to enable the patient to make informed choices about the management of their problem, and are likely to be part of a MDT. Trainees may contribute to the identification of definitive actions for each patient under the supervision of a member of the MDT.
Partnership between patient, rheumatology MDT and referrer may be achieved by any of several means, according to local arrangements and the patient's needs. Direct consultation between patient, referrer and each member of the MDT may be undesirable or impracticable. Definitive actions may be agreed with patients by one or more members of the MDT, with other members contributing through the design of integrated care pathways, and through direct discussion and correspondence regarding the individual patient. Referrer involvement may include referral letter and locally agreed integrated care pathways.
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Documenting definitive actions (Box 3) |
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Clarity of definitive actions will permit subsequent measurement of when they are initiated within the patient pathway, and will facilitate unambiguous agreement of care packages between partners in the patient's care. Definitive actions that will constitute clock stops for the purpose of the 18-week-patient-pathway should all be clearly specified in writing within a single document. Any of a number of documents, with careful design, may be used or adapted for this purpose, for example reconciliation slips, clinic letters, case notes, and written initial care plans.
| Box 3. Documenting definitive actions Definitive actions that will constitute clock stops for the purpose of the 18-week-patient pathway should all be.
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Definitive actions should be communicated in writing to all partners in the patient's care, in a form that can be easily understood, to ensure their agreement. Documentation of definitive actions should be by one or more professionals who, alone or collectively, are competent and qualified to establish diagnosis and/or recommend treatment for the patient's problems. Definitive actions for rheumatological diagnoses or problems for which specialist medical investigation or treatment may be indicated must be agreed with a rheumatologist on the Specialist Register for Rheumatology.
Each definitive action should be characterized as an unequivocal, discrete patient-centred action. Examples may include, provision of a medication to the patient, discussion of the result of an investigation with the patient. Written documentation of all definitive actions should occur as early within the patient pathway as is clinically appropriate. If definitive actions are documented before specialist assessment (e.g. based on integrated care plans), they must include all definitive actions that may be appropriate for the patient's diagnosis and problems. Definitive actions should be documented no later than at the first appointment within specialist care. This should ensure that they are foreseen at the outset of specialist care management, and are determined prospectively based on need, rather than retrospectively based on what has been delivered.
Changes to definitive actions within the 18-week-patient pathway
Only actions identified at the outset of specialist care should be used for the purpose of measuring the 18-week-patient pathway. New actions may be agreed and introduced into the patient's care plan subsequently, but these should not be used to measure the original 18-week-patient pathway. They may comprise definitive actions within a new 18-week-pathway for that patient.
Definitive actions agreed at the outset of specialist care should be considered to be provisional, and the care plan would often be expected to change over subsequent weeks. Care of patients with complex rheumatological conditions is usually an iterative process, whereby changing information and viewpoints lead to changes in what is regarded as optimal management. Definitive actions agreed at the outset of management may become inappropriate and be removed from the patient's care plan, whilst new actions may become essential. Such variances are well-recognized within integrated care pathways and should constitute clock-stops.
Definitive actions may be removed from the care plan in light of, for example, clinical developments, comorbidities, results of investigations, or reconsideration by the patient or doctor. Patients may not be fully equipped to agree definitive actions at the first appointment within specialist care, and may change their opinions as their understanding of their problems changes. Similarly, results of investigations or new symptoms may shed new light on the patient's problems and their optimal management.
Definitive actions may be converted to actions outside the 18-week-patient pathway where clinically appropriate. For example, investigation results may indicate that an alternative treatment should be tried first, or that a comorbidity should be treated before a definitive action can be safely delivered. Patients may equally well choose to defer treatment for personal reasons.
Where a definitive action has been removed from the 18-week-patient pathway, diagnostic procedures that would have led to that action, and treatments that were to be undertaken in advance of it may themselves become definitive. It may be important to document these earlier actions as definitive actions, in order to ensure that the 18-week-patient pathway adequately represents all key aspects of the care package.
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Stopping the clock in the 18-week-patient pathway (Box 4) |
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The end of the 18-week-patient pathway should normally be the start of definitive treatment [4].
Box 4. Stopping the clock in the 18-week-patient pathway
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In light of the complexity of rheumatological problems, and the multidisciplinary and holistic nature of patient care, several definitive actions may be identified that should be pursued concurrently for each patient. Such actions constitute a care package. The care package should be seen as the definitive treatment for that patient. Arbitrary definition of any single treatment as the sole clock-stop in a patient pathway may permit ‘hidden waits’ for other actions within the care package that have not been documented as definitive, despite their essential nature. This emphasis of one action over all others, could be a disadvantage to one or more partners in the patient's care. In order to avoid ‘hidden waits’, it is essential that the clock is stopped for the 18-week-patient pathway only after all definitive actions within the patient's care package have been initiated.
Ideally, all necessary investigations and opinions should be obtained before the definitive actions that they justify are initiated. Investigations prior to treatment should confirm the likely diagnosis, exclude important alternative diagnoses, assess likely prognosis and response to therapy, and identify any factors that may compromise response or increase the likelihood of adverse events. Such investigations may include, but will not be limited to radiology (e.g. magnetic resonance imaging, bone scan, ultrasound), blood tests (e.g. immunology), DEXA scanning, and tissue biopsy/aspiration and analysis. Opinions may include a psychological or vocational assessment.
Different members of the MDT may initiate definitive actions, in different departments within a single NHS Trust, or in different organizations. Stopping the clock should be irrespective of where definitive actions are initiated, and should only occur after there has been adequate communication between partners in the patient's care. For example, undertaking an MRI scan should not stop the clock until the findings have been communicated to the patient and referrer and their relevance discussed. Prescription of a disease modifying agent should not stop the clock unless the patient has been provided an appropriate mechanism for active monitoring and adequately counselled about the treatment.
Sometimes the clock may stop even though all definitive actions have not been initiated [4]. Definitive actions may be removed from the care plan, and a decision not to treat or to begin watchful waiting or active monitoring may be agreed with the patient. Furthermore, the clock will stop at discharge to primary care following inability to agree a suitable appointment date or a ‘Did Not Attend’ at the first appointment on the pathway, where the provider can demonstrate that the appointment was reasonable and clearly communicated to the patient.
In addition to clock-stops, where a patient leaves their 18-week pathway, there will also be facility for patient-initiated delays [4]. This may be necessary to allow the patient time for reflection, or due to other family or personal circumstances (e.g. recent bereavement). However, it is important that lack of local availability or accessibility does not force patients to delay treatment. Patient's who delay, should be able to rejoin their pathway at any reasonable time prior to discharge from specialist care and thereby recommence their treatment without disadvantage.
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On-referral during the 18-week-patient pathway |
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Where on-referral to another speciality within or outside the secondary care organization is necessary in order to deliver the care package, this should be identified at or prior to the outset of management within specialist care. On-referral may be necessary, in order to obtain a specialist opinion, to pursue diagnostic testing or to deliver treatment.
For consultant-to-consultant referrals where the underlying condition remains unchanged, the mere act of making a tertiary referral or a referral from one provider to another will not stop the clock in the 18-week-patient pathway [4].
On-referral may be for an opinion. Communication of that opinion may itself constitute a definitive action. For example, where a decision on whether surgery should be pursued depends on the opinion of the surgeon, then referral from rheumatology to the surgical unit would be for an opinion, rather than for surgery. Such an on-referral would only initiate a new 18-week pathway for the patient (for example, with respect to surgical treatment) if it were not for the original underlying condition or problem.
Often an opinion may be necessary, in order to confirm that it is appropriate for the referring rheumatologist to deliver a definitive action. That opinion should be provided in a timely fashion to permit initiation of the definitive action within the 18-week-patient pathway. For example, if a patient is referred to rheumatology with a provisional diagnosis of Systemic Lupus Erythematosis and renal biopsy is required to define the appropriateness of immunosuppressive therapy, then the clock would not stop until an appropriate nephrological opinion had been obtained and immunosuppressive therapy either initiated or excluded.
On-referral will be necessary if a definitive action would be more appropriately delivered outside the referring rheumatology department. All definitive actions should be initiated within the 18-week-patient pathway, irrespective of where they will be delivered. For example, if a patient were referred to a Rheumatology Department for management of their carpal tunnel symptoms, the care package may include surgery as a definitive action. Surgery should then be completed within the 18-week-patient pathway. The appropriateness of defining surgery as a definitive action within the initial rheumatology consultation may depend on the agreement of appropriate integrated care pathways with other partners (e.g. orthopaedic surgeons and primary care).
On-referral should be included within the 18-week-patient pathway only where it is necessary, in order to deliver definitive actions that could be anticipated from the original referral. Problems that are identified subsequent to the original referral that do not relate to the original patient condition may trigger the start of a new 18-week-patient pathway. The clock for the original 18-week-patient pathway may continue beyond the start of the new pathway (overlap) if definitive actions identified from the original referral remain outstanding and appropriate.
In many situations, definitive actions will be provided outside the secondary care organization that has accepted the referral, for example within primary care (e.g. by the referrer), through social services, or by an alternative specialist care provider. The 18-week-patient pathway should be measured irrespective of the care provider and on-referral should not of itself constitute a clock-stop. For example, if a patient with rheumatoid arthritis is referred to the Rheumatology Department, commencement of a disease modifying agent may be documented as a definitive action. If local agreements are in place that such treatments are initiated by prescription from primary care in partnership with the rheumatology MDT, then the Trust and the patient's general practitioner should ensure that treatment is commenced within the 18-week-patient pathway. As with other on-referrals, an explicit recommendation to treat, should be clearly distinguished from a request for assessment or opinion as to whether such treatment would be appropriate.
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Referral interface between primary and secondary care |
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The 18-week-patient pathway has been applied to primary-to-secondary care referrals. Failure to apply similar pathways to tertiary (secondary-to-secondary care) referrals could be a disadvantage to patients already within secondary care. However, application to tertiary care referrals will require local agreement with commisioners, or local processes by which such tertiary referrals may efficiently be administered through primary care, thereby coming under primary-to-secondary care 18-week-patient pathways.
Clinical Assessment and Treatment Services (CATS) are strongly supported within the Musculoskeletal Services Framework [5]. Similarly, use of referral-management services and the independent sector may facilitate patient care. The constitution of CATS and independent sector services must adequately address issues of training, accreditation and ongoing professional development and peer support that are necessary to provide those specialist services that are placed under their responsibility.
Where clinical interface services exist, it is important that they contribute to the efficient provision of effective health care, and do not add to the wait from referral to treatment. It may not be known at the time of referral to an interface service whether consultant-led specialist care will be the most appropriate management option. However, as this may be the case, all referrals to such services will start the clock for an 18-week-patient pathway, whether or not the service is based in primary or secondary care [4].
Service redesign, in order to minimize inappropriate waits may result in transfer of responsibilities between secondary and primary care. It is essential that any such transfer does not lead to hidden waits for the patient. For example, it may be desirable that investigations normally pursued in secondary care are instigated from primary care, following agreed integrated care pathways, so that results may be available at the first out-patient appointment in secondary care. Such ‘straight to test’ arrangements, where a referral is made to a consultant-led service, with the patient sent straight for diagnostic testing rather than an initial consultant consultation, fall within the 18-week pathway. Direct access diagnostics (where no referral to a consultant is made) are not within the 18-week pathway. Request and review of investigations in primary care should not delay appropriate specialist referral.
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Recommendations |
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The feasibility of implementing these guidelines should be piloted prior to the national implementation of the 18-week-patient pathway in 2008. Commissioners and secondary care Trusts should audit and evaluate the 18-week-patient pathway for patients with rheumatological problems after their implementation. It is essential that local providers establish robust mechanisms, in order to document the extent to which the 18-week-pathway is achieved, and to explore reasons for any inability to achieve it. Possible areas for audit and evaluation are given in Box 5.
| Box 5. Audit and evaluation of the 18-week-patient pathway in rheumatology Suggested Audit Standards:
Suggested Evaluation Questions:
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Conclusions |
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Implementing the 18-week-patient pathway should facilitate the delivery of high quality care to patients with rheumatological conditions without unnecessary delay. The pathway should be interpreted in the context of evidence-based guidance on best practice in rheumatology. Patients benefit from care packages that contain actions taken by different members of the MDT, several of which may be regarded as definitive actions. Definitive treatment can validly be said to have started once all definitive actions within the care package have been initiated. Care packages are patient-centred and agreed between all partners in their care. Agreement and measurement each require clear documentation and communication. The complexity of rheumatology care confers a challenge to the valid measurement of referral to treatment times, but success in this challenge has great potential for optimizing services.
The Musculoskeletal Services Framework highlights the current context of care for patients with rheumatological conditions and illustrates potential barriers to the delivery of an 18-week-patient pathway within current NHS structures. Service redesign will be necessary to achieve the 18-week-patient pathway for all patients with rheumatological conditions. Services may need to be developed to relieve bottlenecks and other barriers to timely treatment. Redesign may also often be necessary in order to facilitate full and rapid assessment of the individual patient's needs in order to agree the definitive actions that will be included in their care package. Implementing change within the NHS has historically presented a number of challenges. Clarity of responsibility, purpose and motivation are each important in implementing change. Change is likely to involve a redistribution of resources. If resources are to be linked to definitive treatment, it will be essential that key aspects of the care package are recognized within that definitive treatment.
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Acknowledgements |
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The authors wish to thank all those who have contributed to these guidelines during their development, including members of the British Society for Rheumatology Council and Clinical Affairs Committee, British Healthcare Professionals in Rheumatology, the National Rheumatoid Arthritis Society, the British Pain Society and the Department of Health (England). We are grateful for all suggestions from individuals, including Ray Armstrong, Simon Bowman, Karishma Chandaria, Chris Deighton, Daniel Fishman, John Halsey, Jackie Hill, Ken Lim and Vadivelu Saravanan.
CP has received consultancy fees from Axon Communications for work on service redesign in pain management. This has been sponsored by NAPP Pharmaceuticals. CP has also received honoraria from Janssen-Cilag and Pfizer UK to talk at clinical meetings. CP has received research support from Pfizer UK.
AB's charity, NRAS, has received a small amount of sundry honoraria and also annual educational grants from a number of pharmaceutical companies who have drugs for R.A.
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References |
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