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Transforming elective recovery across NHS South East

The Challenge
In 2021, NHS England and NHS Improvement – South East Region commissioned Four Eyes Insight to support their Elective Recovery Support Programme in the South East of England. Following the pause of all elective activity due to the COVID-19 pandemic, elective waiting lists across the South East region had grown significantly, increasing waiting times on already pressured services. The pause caused a significant increase of patients waiting 18+ weeks for treatment. Therefore, the challenge was to implement our programme of support with the objective of ensuring each of the six trusts nominated across the South East region, had a robust recovery plan for high volume services.

Our Approach
This was a 16-week programme, covering 6 Trusts, (1 Trust from each integrated care system across the South East region) focusing on 3 specialties – Orthopaedics, ENT, and Ophthalmology. We sought to build robust and deliverable improvement plans as well as to support the identification and implementation of ‘quick wins’ to inject pace into the programme.

We began with a rapid initial data gathering exercise to establish current and historic performance levels; this information was validated with clinical and operational teams. Next, we gained feedback from focussed specialty-level team meetings and on-site observations, including 6-4-2 meetings and Theatre Utilisation Review meetings, and presented the key findings and initial recommendations to the programme board and SROs.

During the second phase we co-developed and agreed bespoke improvement plans for each Trust and commenced the monitoring, delivery and reporting against the plans. Our teams ensured delivery of plans was kept on track for the duration of the engagement and ensured mitigation actions were devised and taken when required. In addition, we conducted a Capability and Capacity Assessment for each Trust with KPIs, and improvement trajectories developed, agreed, and monitored as part of internal Trust governance processes.

The Results
The FEI team started with an initial data analysis exercise which drew a comparison between current and historic (pre-pandemic) performance levels. This allowed a pre-pandemic baseline to be established which permitted the accurate measurement of relative performance and activity going forward. For example, the initial analysis highlighted early on that late starts in theatres were an issue across the region, and this was validated directly with clinical and operational leads for each specialty.

A key component of the recovery programme was the identification and sharing of best practice across the South East region. Areas of best practice were identified during our key engagement and observation sessions, i.e., 6-4-2 and theatre utilisation. Some of the key cross-cutting recommendations from across the programme were implementation of the perfect morning to address late starts, revisions to in-house opportunity reporting and re-visiting theatre/estate utilisation. FEI also led region-wide and Trust-specific training sessions, with good engagement from clinical and operational teams.

Organisational good practice was also shared across the region. For example, during our observations we identified that the 6-4-2 process at NHS Trust 1 represented regional best practice. It incorporated key elements of an efficient and well organised 6-4-2 meeting, which were shared with other organisations in the region, ensuring the teams are looking 6 weeks out, with good levels of engagement and regularly addressing any blockers.

The recommendations were further supported by the FEI admitted PTL tool to explore the backlog, looking at key criteria such as weekly additions, patient priority, procedure types, average touch times and regional comparators. Utilising this data, demand and capacity modelling was undertaken for each provider, focusing on scenario-based trajectory modelling to improve activity levels to 120% of pre-pandemic levels. For example, the scenarios in the Ophthalmology service at NHS Trust 2 are shown in the graph below, with different session lengths, theatre utilisation (%) and weekly additions to the waiting list used to map the different scenarios.

There was a positive outcome at both system and Trust level, with each Trust having signed-off robust recovery plans, which Trusts are currently implementing. Capability and capacity assessments were also conducted for each recovery plan, highlighting areas that may need executive support. Improvement plans were also supported through in-depth data analysis. For example, NHS Trust 3 now have an elective recovery improvement plan in place, consisting of 22 actions covering 5 distinct areas, with time scales and owners, which clearly lays out an agenda for continued improvement.

A range of KPIs were established and formed an integral part of the recovery plans, that ensured the plans were robust and these indicators will be used to monitor the impact of improvement actions.

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Establishing a £2.4m threatre efficiency programme

The aim was to establish, implement and deliver a significant £2.4M theatre efficiency programme in Trauma and Orthopaedics (T&O). This would be achieved through improving ‘in-session’ efficiencies, increasing case-mix and changing individual surgeon list templates.

Given the Trust’s challenging financial position and significant variance of T&O performance to 2015/16 financial plan, this programme was needed to give them the necessary tools to get back on track. Ensuring savings identified in T&O theatres was a real priority.

Improving outpatient clinic efficiency through communication

Once the Four Eyes diagnostic review was complete, 5 specialties were chosen for our first wave of implementation. After the success of this implementation the Trust has commissioned Four Eyes to develop demand & capacity models for the hospital’s outpatient clinics.