Evidence-based Interventions: aligning with system recovery

Evidence-based Interventions:aligning with system recovery

Professor Helen Stokes-Lampard, Chair of the AoMRC

Professor Martin Marshall

Professor Sir Terence Stephenson

Rachel Power

Dr Graham Jackson

Professor Chris Moran

Welcome

Professor Helen Stokes-Lampard

Academy of Medical Royal Colleges

— High quality evidence-based care is a priority

— Ensure clinicians provide effective care to those who need it

— Strategic alignment with Urgent and Emergency Care

— Clinical Validation and challenge of the waiting list

EBI: Key drivers

Evidence-based Interventions programme

Improving the quality of care

Reducing harm to patients

Maximising use of scarce resource

Minimising unwarranted

variation in service provision

Encouraging doctors and

patients to reflect on treatment

recommendations

— Launched in 2018 as a clinically led, quality improvement programme

— Joint venture between AoMRC, NHSCC, NICE and NHS England & Improvement

— Published list 1 in November 2018

— Established independent Expert Advisory Committee May 2019

— Published list 2 in November 2020

Background to EBI programme

A clinically-led Expert Advisory Committee was established in May 2019 to provide independent leadership, advice and guidance to the EBI programme.

The independent Expert Advisory Committee

Committee membership

Committee mandate

Chairs— Professor Sir Terence Stephenson, Chair of the Health Research Authority

— Professor Martin Marshall, Chair of the Royal College of General Practitioners

Membership includes— Patient voices

— Senior clinicians

— Experts on public health

— Clinical commissioners

— Experts on value in healthcare

— Guideline producers

The committee was asked to— Recommend a list of interventions proven to be inappropriate based on clinical evidence

— Draft clinical guidance based on rigorous evidence and stakeholder consensus

— Lead engagement programme with relevant Medical Royal Colleges and sub-specialty groups, patient groups and the public

— Maximise implementation of evidence-based guidance

Introducing

Professor Sir Terence Stephenson

Chair, Health Research Authority

Peer-reviewed Literature review(BMJ, Lancet etc)

Scoping review

Data analysis / clinical coding

(HES + / variation)

Suggestions from the system

(Consultation, individual, societies)

Grey Literature review (NICE, POLCE,

GIRFT, CW, etc.) Long-list:

Apply exclusion criteria

Long – list selection

Clinical guidance(NICE, NICE-

accredited, others)

Data analysis (Volume, variation,

clinical coding)

Evidence review

Short-list:

Clinical agreement, including patient

viewsand coding consensus

Short – list selectionNational support for

criteria / coding

Providers (medical directors, financial directors)

Clinicians(Royal Colleges,

Specialist Societies, Clinical

Commissioners )

Patients (individuals, patient

groups, etc)

Patient reported outcome data

Financial analysis (Volume and spend)

Commissioners(Demonstrator sites, NHSCC)

Technical(finance, data, CSU,

clinical coding)

Shortlisting the recommendations

Process for shortlisting

EBI Guidance (List 1 & 2)

— Diagnostic coronary angiography for low risk, stable chest pain

— Repair of minimally symptomatic inguinal hernia

— Surgical intervention for chronic sinusitis— Removal of adenoids for treatment of glue ear— Arthroscopic surgery for meniscal tears— Troponin test— Surgical removal of kidney stones— Cystoscopy for men with uncomplicated lower

urinary tract symptoms— Surgical intervention for benign prostatic

hyperplasia— Lumbar Discectomy— Lumbar Radiofrequency facet joint denervation— Exercise ECG for screening for coronary heart

disease— Upper GI endoscopy— Appropriate colonoscopy in the management

of hereditary colorectal cancer— Repeat Colonoscopy— ERCP in acute gallstone pancreatitis without

cholangitis

— Cholecystectomy— Appendicectomy without confirmation of

appendicitis— Low back pain imaging— Knee MRI when symptoms are suggestive of

osteoarthritis— Knee MRI for suspected meniscal tears— Vertebral augmentation (vertebroplasty or

kyphoplasty) for painful osteoporotic vertebral fractures

— Shoulder Radiology: Scans for Shoulder Pain and Guided Injections

— MRI scan of the hip for arthritis— Fusion surgery for mechanical axial low

back pain— Helmet therapy for treatment of positional

plagiocephaly/ brachycephaly in children— Pre-operative chest x-ray— Pre-operative ECG— Prostate-specific antigen (PSA) test— Liver function, creatinine kinase and lipid

level tests – (Lipid lowering therapy)— Blood transfusion

EBI list 1 can be accessed via NHS England & NHS Improvements websiteEBI list 2 can be accessed vis the Academy of MEDICAL Royal Colleges websiteThe EBI dashboard can be accessed via the NHS BSA website

— Snoring Surgery (in the absence of Obstructive Sleep Apnoea (OSA)

— Dilatation and curettage (D&C) for heavy menstrual bleeding in women

— Knee arthroscopy for patients with osteoarthritis

— Injections for nonspecific low back pain without sciatica

— Breast reduction— Removal of benign skin lesions— Grommets for Glue Ear in Children— Tonsillectomy for recurrent tonsillitis— Haemorrhoid surgery— Hysterectomy for heavy menstrual bleeding— Chalazia removal— Arthroscopic shoulder decompression for

subacromial shoulder pain— Carpal tunnel syndrome release— Dupuytren’s contracture release— Ganglion excision— Trigger finger release— Varicose vein surgery

EBI phase 1 EBI phase 2 EBI phase 2

Average NHS time taken for 1 procedure: 370mins per patientIn 2017/18 we carried out 3,432 procedures which amounts to 881 days

Knee arthroscopy for patients with osteoarthritis

Knee arthroscopy should be not be used as treatment for osteoarthritis because it is clinically ineffective

Introducing

Rachel Power

Chief Executive of the Patients’ Association

Accessible language

Full and clear explanation

Honest analysis of options and potential outcomes

Patient information leaflets

Question and Answer

Please put any questions you may have in the chat box

EBI implementation and its importance for systems

Dr Graham Jackson

NHS Clinical Commissioners/

NHS Confederation

Clinical prioritisation of waiting lists Elective Recovery

Professor Chris Moran

NHS England and NHS Improvement

Introduction

BackgroundThe Clinical Prioritisation programme is part of the third phase of the NHS response to COVID-19 and is designed to support the prioritisation of waiting lists as part of the recovery of elective activity. The programme has been developed in conjunction with stakeholders and is supported by NHS North of England Commissioning Support.

Key aims— Prioritise access to procedures based

on individual patient needs but taking into account the need of the population

— Facilitate good communication between patient, GP and secondary care provider

— Produce an accurate waiting list enabling appropriate patients to access care

— Minimise waits where possible but particularly for those with immediate need

— Recognise that for less urgent or routine diagnostics, some patients may experience a delay

Principles— The backlog of surgical, diagnostic & outpatient procedures needs to be prioritised

according to clinical need rather than waiting time— Take a holistic approach to patient care and consider if there are alternative

pathways that are appropriate and available and with capacity— Local design and delivery of the validation process: Core standards but local design

and application with specialist advice — Clinicians and organisations that have already started validating their waiting lists

should NOT stop— We must narrow rather than widen health inequalities - e.g. pro-active support for

people without English as first language; appropriate arrangements for those with learning and behavioural difficulties; avoiding digital inequalities

— In summary, the project is about and making the best recommendations for diagnostic pathways and reviewing the current indications for investigation.

The requirement to clinically prioritise waiting lists has been set out as a required gateway for elective recovery funding.

Clinical prioritisation

of waiting lists

Most long-waiting patients on the waiting list will have agreed to undergo operative treatment or a diagnostic procedure before the coronavirus pandemic started. Many people’s circumstances may have changed as a result of the pandemic or other factors since then, and some patients may now have changed their minds about having surgery or wish to defer this until the pandemic is over. Similarly, some people’s condition may have changed, which they may not have wanted to inform their GP or specialist about.

The clinical prioritisation of waiting lists project will produce a clinically prioritised list that allows waiting lists to be managed effectively, by:

— checking on a patient’s condition and establishing any additional risk factors

— establishing the patient’s wishes regarding treatment

— providing good communication with patient and carer and GP

— introducing categories that allow patients to postpone surgery but remain on the waiting lists

This project is supported by the Academy of Medical Royal Colleges as well as relevant medical Royal Colleges and specialist societies. It has been reviewed by the NHS England and NHS Improvement legal cell.

Validation and prioritisation stages

1. Technical Validation*

Remain on waiting list or

Alternative pathwayor

Remove from waiting list

1. Technical validation: ensure the waiting list is accurate and up to date.

2. Patient discussion: patients are contacted by a locally determined competent team to establish their wishes.

3. Remote clinical consultation: for patients who wish to discuss their situation in more detail using shared decision making (SDM).

2. Clinician review (prioritization**)of referral +/- medical records

3. Remote clinical Review

(prioritization**)

*Validation is an administrative function ensuring waiting lists are correct and up to date.

**Prioritisation is the process of categorising patients according to clinical need, which should be undertaken by an appropriate clinician in accordance with the national guidance on clinical validation of surgical waiting lists

Clinical prioritisation of clinical waiting lists

Most long-waiting patients on the surgical waiting list will have agreed to undergo operative treatment before the coronavirus pandemic started. Many people’s circumstances may have changed as a result of the pandemic or other factors since then, and some patients may now have changed their minds about having surgery or wish to defer this until the pandemic is over. Similarly, some people’s condition may have changed, which they may not have wanted to inform their GP or specialist about.

The clinical validation of surgical waiting lists project will produce a clinically validated waiting list that allows operating lists to run effectively, by:• checking on a patient’s condition and establishing any additional risk

factors — establishing the patient’s wishes regarding treatment— providing good communication with patient and carer and GP— introducing the P5 and P6 categories that allows patients to

postpone surgery but remain on the waiting lists

This project is supported by the Academy of Medical Royal Colleges (AoMRC) as well as relevant medical Royal Colleges and specialist societies. It has been reviewed by the NHS England and NHS Improvement legal cell.

Surgical waiting list prioritisation codes*

<1 month P2

<3 months P3

>3 monthsDelay 3 months possible

P4

Patient wishes to postpone surgery because of COVID-19 concerns**

P5

Patient wishes to postpone surgery due to non-COVID-19 concerns**

P6

* Based on the prioritisation tool produced by the Federation of Surgical Specialty Associations and endorsed by all surgical colleges: https://fssa.org.uk/_userfiles/pages/files/covid19/prioritisation_master_240720.pdf

** This decision needs to be discussed with the patient within six months.

Use of shared decision making

Admitted Pathway Validation - UnderwayProviders of NHS healthcare have actively

engaged in the programmeOver 80% of patients who are on admitted

waiting lists have already been reviewed and prioritised into one of the four clinical

categories.Identified patients who would prefer to wait

for their procedure until after the pandemic or no longer require the treatment.

Diagnostic ValidationDocument pack to support roll out completed

& awaiting publication Pilot sites commenced Nov 2020

Ongoing engagement with key stakeholders

Outpatient/Non admitted Validation –Scoping Underway

Currently scoping with relevant stakeholders Baseline assessment being drafted

Develop prioritisation codes with clinicians

The Clinical Prioritisation programme is part of the third phase of the NHS response to COVID-19 and is designed to support the prioritisation of waiting lists as part of the recovery of elective activity. The National Clinical Validation programme continues, with trust level reviews ongoing.

The below indicates the current and future stages of the programme.

Question and Answer

Please put any questions you may have in the chat box

Thank you for joining us

Professor Helen Stokes LampardAcademy of Medical Royal Colleges

If you have any queries please email us at [email protected]