In January 2019, the Digital Health and Care Institute (DHI) began work with the NHS Scotland Breast Surgery Specialty on improving surgery pathways for patients and staff. Under the umbrella project The Scottish Access Collaborative, the specialty group and the DHI team will work together to unpick current breast surgery services and make recommendations for service innovations based on the findings and insights gathered over the coming months.
The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures. The program is guided by its six founding principles which foreground patient experience, clinical benefit, and transparent services. The six principles can be seen here.
The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.
The DHI was commissioned by Scottish Government to design workshops for the Scottish Access Collaborative clinical specialty-led programme. These workshops involve a range of clinical staff from primary and secondary care, health managers, patients and third sector organizations undertaking a cycle of design-led workshops.
In this first workshop, the aim was to map out the common symptoms and conditions breast surgery deal with currently as part of their non-acute out-patient service, and prioritize what issues the group want to focus on in the next two workshops.
Common Symptoms: Why focus in this?
During a morning of discussion around common symptoms and opportunities for improvements, the group focused in on a number of areas for focus for the next two workshops.
To help prioritize the aims for the next two workshops, it was useful to reflect on each common symptom and ask ‘why’ this would be a good area to focus on.
Cross Cutting Issues
Issues for general surgery that cut across the majority of symptoms include:
The next steps for breast surgery will be to dig deeper into the issues and opportunities for the identified prioritised areas and highlight any recommendations for service improvements in line with the Access Collaborative principles. This will take place over two further design workshops facilitated by the DHI team. While the Access Collaborative aims to develop new ways of working for NHS services, there is also recognition that there are national work programs already underway as well as existing innovations in individual boards and hospitals. Over the coming months the DHI team will also work with the breast surgery group to promote relevant national initiatives and share examples of best practice through this blog.
If you would like to know more about this work or would like to attend the next workshops, please contact the DHI project team via email
Earlier this year (2019), the Scottish Access Collaborative Breast Surgery Specialty met again for a second design workshop. Following an initial workshop where the current state of Breast Surgery services in the NHS were mapped and common symptoms and issues discussed, the second workshop would focus on ideas for service innovation and improvements. It began with a recap of the symptom profiles and the associated key issues for Breast Surgery identified in workshop one. We also did a quick recap of the ‘how might we’ challenges for Breast Surgery developed in workshop one. The how might we challenges serve to focus attention on a particular issue or opportunity in the NHS so the group can hone in on particular innovation opportunities. The recap was followed by group breaking away into two working teams, each taking a symptom and the associated how might we challenge, adding some detail to the key issues for each challenge, developing some ideas for service improvement, and developing action plans with steps to take the ideas forwards. One team worked on the symptom ‘pain’, and the other worked on the symptom ‘lump’.
The following summarises the symptom profile, the issues, the challenges, the ideas and the action plans from each team.
Symptom Summary: Pain or tenderness is the second most common symptoms in referrals. There is an issue around health messaging via public sources linking it to cancer and creating unnecessary worry and expectation. Distinguishing between chest wall and breast pain is an issue, as is variation in referral and imaging practice nationally despite clear guidance.
How might we: the challenge for pain was summed up as;
Symptom Summary: Lump is the most common symptom among urgent referrals but the term is not strictly defined. There are issues around non-clinical messaging regarding breast cancer that leads to high anxiety. Education is an issue, as well as pathways that deal with benign lumps seriously but without unnecessary imaging.
How might we: the challenges for lump were summed up as;
The recommended next steps would be:
This will need:
Specific actions include:
The challenges to this will be:
The outcomes of this could be:
The recommended next steps to improve education would be:
This will take:
Specific actions include:
The challenges could include:
The potential outcomes could be:
The recommended next steps to empower patients would be:
The specific actions could be:
The barriers to achieving this could be:
The recommended next steps to a simplified referral process with current guidelines would be:
The specific actions could be:
The barriers to achieving this could be
The next step will be to re-visit the remaining symptoms and to develop new how might we statements, develop more ideas to address the challenges, and develop the associated action plans. All the agreed actions will be documented as recommendation in the Breast Surgery report to be published via this site.
In March 2019, the Scottish Access Collaborative Breast Surgery specialty met for their third and final design led workshop facilitated by the Digital Health and care Institute. The ultimate aim of the collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. For Breast Surgery, this involved mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the previous two Breast Surgery workshops, some common symptoms were proposed and some common issues identified, resulting in a number of specific symptom profiles and challenges for current service designs. Small working groups re-framed these current challenges as a series of ‘how might we’ statements, that positively re-states an issue as an opportunity for change. In the previous workshop the group tackled some of these challenges, developing some ideas for innovation and action plans for the next steps. In this third workshop, small working groups revisited the remaining ‘how might we’ statements, selecting the most salient and developing some more ideas and action plans.
What follows are short summaries of the ‘how might we’ statements that the Breast Surgery group prioritised in the workshop, the symptom profiles they relate to, the group responses to the challenge, and some more action plans for next steps.
Ideas and Actions
For primary care, educational events for primary health practitioners. Paid for educational time for primary care, GPs and ANPs visit clinics and specialists go to GP practices. For patients, a single information sheet detailing what to expect from a visit to clinic, both for low and high risk cases. Patient information should be easily accessible, available physically and digitally, with an infrastructure to maintain and keep up to date. This needs to be unified across Scotland. The change needs to use unified referral guidelines across all boards. Advice only referrals rolled out across the country. When referrals are returned, this should be with information and support, referring the referrer to online advice, opening a dialogue with GPs and ANPs. This will take dedicated triage time in job plans.
If implemented, this change would result in fewer inappropriate referrals, fewer anxious patients, fewer miles travelled by patients, less imaging and better informed public and health workers. Measures of success would reflect in adherence to the guidelines, more people seen via a low risk pathway, increased patient satisfaction. Conversely, some patients may be unhappy at not being given a secondary care appointment. This may lead to more work for primary care to reassure patients.
The first steps in making these changes would be to develop the unified national updated information online to support patient education. Allowing paid for time for primary care would unlock the potential for visits to clinics and time spent with visiting consultants. The main actions are to introduce enhanced vetting, allowing time for informative responses with links to online information, to develop centralised information, and also to roll out a single Ref Help and advice only referrals across Scotland. The challenges for this change will be funding the time for vetting, staffing in general for all areas, and the fact that it will take longer for primary care not to refer and this needs to be recognised.
There was a wider discussion about the role of radiologists and the location of imaging services. It was recognised that there are not enough radiologists to deal with demand, however, the answer is not just more radiologists. In response, two items were recommended. Firstly, that the imaging workforce can be expanded by extending some existing roles for example ANPs. Secondly, that by co-locating imaging services more women would be seen more quickly. These recommendations cross over with other discussions from other working groups.
Right Clinic. Right Time.
Develop enhanced forms that are aligned with national cancer guidelines for urgent referrals, and aligned with and linked to advice for routine referrals. For GPs, this should be a very simple resource as part of referral software. For patients, they could ‘self-triage’ using online resources that are authored and endorsed by NHS Scotland. Imperative will be that the ‘vetter’ must add value, for example by either rejecting, redirecting, or downgrading the referral.
The result of a simple enhanced referral system, that includes patient self-triage and active vetting would be that many patients would avoid a trip to clinic, and receive early reassurance. The success of such a change would reflect in a reduction in referrals, and reduced waiting time for those who do come to clinic. Rejected referrals would feed-back support and advice helping to educate GPs and patients. A potential negative impact to consider is that both patients and GPs may feel they are being ‘fobbed off’ by the new processes and this should be considered in any new service design.
The first step to making this change will be to collate existing current information that is available for breast surgery, for GPs and patients. There needs to be a discussion about how much information is ‘right’ to send to patients. There also needs to be a discussion about changes to current vetting practice, perhaps supported by the SAC and other ongoing national pieces of work around vetting. It will be important to decide on and use the right language around referrals, for example considering the perception from language like ‘rejection’ and ‘declined’ and how this impacts on how GPs and patients feel.
The idea is for an age stratified referral pathway for pain and gynaecomastia referrals. Under certain conditions that will be agreed for Scotland, for example for people under 30 years of age, a low risk pathway would offer reassurance, advice and information, rather than offering a clinical slot and imaging. There would be information available for primary care at the time of referral plus sufficient vetting time for secondary care to actively triage referrals to the low risk pathway where appropriate. A successful change to a low risk pathway would create a person-centred pathway, offering appropriate reassurance and access to clinics for those who need it. It would benefit patients, GPs and consultants with reduced cancer waiting times, better access to services for those who need them, and fewer referrals overall. The change will require consultant time for vetting and triage, as well as standard, quality information for patients.
The first step to developing the low risk pathway will be to collate existing patient information sources and referral guidance, looking for assets and variation across boards, with a view to standardising what is available. This will involve collaboration between primary and secondary care, national IT expertise, service managers and third sector and patient groups. In the next phase, there will be a need for a clear communication strategy through the NHS, media, social media and physical posters. NHS systems will need to be updated and developed for the new pathway, for example advice only. The clinical groups involved in the development of this pathway should engage with the SAC ACRT program of work looking at active triage. They should also be sharing their own examples of best practice with referrals. The outcomes from an implemented action plan leading to a low risk pathway would be a reduction in clinical waiting time, fewer referrals, reduced anxiety in population, and an overall better quality service.
In order to expand the imaging service, the group concluded that first of all the training numbers must go up and specialist registrars must be enthused. In order to retain an imaging workforce issues like pensions need to be addressed and flexible working introduced and embraced. There should be a balance between screening, symptomatic, and general radiology work, with consistent national banding, to make the job attractive. Advanced practice roles for mammography was discussed, along with the potential of co-location of screening and symptomatic services. In terms of equipment provision, there would need to be sufficient numbers of mammography and ultrasound units. If the changes could take effect, the impact would be visible by an improved service quality, with a balanced team, better staff retention, and a standard pay scale.
To move this idea forwards will initially involve radiologists, radiographers, service managers, MDTs and trainers. In terms of available assets, the stakeholders should look at current equipment capacity, especially looking for instances of underutilisation, and also the current training programs available. The aim will be for developing methods and incentives for ongoing role extension, and new breast radiology recruitment with better retention. In the future, the idea is to develop mentors for supporting ongoing development, co-locate the screening and symptomatic services, and address the pensions issue. Key challenges to the changes being suggested will be achieving uniformity of banding and securing pension changes.
This idea focusses on a re-education strategy that would enact what is already currently available in terms of education and guidelines into protocols. Key to this change would be an understanding of the current situation regarding protocol adherence. The suggestion is that an audit that plots the requests for imaging against the current protocol would help to highlight an issue and make a case for change. This will involve access to as complete a set of current data from across the boards as possible. Key to any implementable change in protocol will require sufficient change management, rather than a reliance on things changing as a matter of course.
If successful, better protocol compliance would result in a consistent approach across Scotland, fewer requests for imaging, which would free up imaging slots for those who need it, increasing radiology capacity. There would also be fewer appointments for patients who do not require imaging, reducing unnecessary exposure to radiation.
To action such a change in a national protocol we would need to engage secondary care clinicians, radiology and service managers. The aim would be to develop imaging guidelines into local and national protocols. The first steps will be to gather the data on variation via the audit of requests versus number of patients seen. This data would be fed back to clinicians. To achieve this there will need to be some protected time for clinicians to be released to cover the audit, education and service development based on protocol. Challenging to this change will be the clinical and service management and getting access to the required data.
The next steps for the SAC Breast Surgery work will be for the DHI design team to collate the recommendations from across the three design workshops into a final Breast Surgery report that will be presented to the SAC board later in the year. Prior to it being taken to the board participants from the three workshops will have the chance to review the draft report before a final version is agreed. Once agreed, the final report will be published through the Turas website.