This Urology Blog will keep track of all the activity undertaken by the Urology Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wished to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
Urology Workshop One
On Thursday the 10th May the Urology Specialty Group met for the first time at the Stirling Court conference centre for their initial Scottish Access Collaborative workshop (for more detail on the Scottish Access Collaborative please read the project homepage). The design led workshop, supported by the Digital Health and Care design team, was the first of a series of three design workshops aimed at mapping and understanding the current state of clinical pathways for Urology, share best practice, uncover variations, and develop a prioritised list of key challenge areas that can help to improve Urology services and bring down patient waiting times. To begin the meeting DHI design director, Elizabeth Brooks, spent some time introducing the concept of the Scottish Access Collaborative, its aims and the aims of the three design workshops to the cross-board assembly of health care and government professionals who make up the Urology group. After the brief introduction, the DHI team led the discussion between the group of consultants, nurses, GP’s and other health professionals, with the aim of mapping out current Urology pathways and finding some high-level challenge areas.
Before defining key challenge areas for any existing system, it is important to develop an understanding of its current state, complexity, and variations. Visually modelling or mapping a system allows for groups to develop that shared understanding of what is currently ‘happening’, as well as visualise what is a very complex set of actions and consequences that can be difficult to hold in the imagination all at once. In order to break down the whole system into manageable elements we have chosen to use individual symptoms as the unit of analysis, and so the first task for the group was to develop Urological symptom profiles based on their experiences of working in their environments. The group listed the most common, interesting or challenging symptoms that they deal with in their profession and the reasons why each should be of interest for The Collaborative. The idea being that once an agreed set of symptom profiles had been established, models of pathways would be visualised based on individual profiles, thus making the task more manageable. So the next task for the group was to discuss and decide what symptoms to map and why. In all the group focussed on four symptoms:
Visible blood in the urine: chosen because it is a symptom that is directly referred to secondary care and so there is a high volume of presentations, it can link to cancer pathways and so is a ‘red flag’ symptom, yet it is nuanced and can have multiple diagnoses
Urine leakage and trouble passing urine: two symptoms that were chosen together because of their similar nature
Leakage was chosen because it is a symptom that has a large presentation in primary care, it is considered one of the biggest issues in the country in terms of symptom presentation, it is dealt with well in primary care, and it has multiple entry points often through gynaecology
Trouble passing urine was chosen because similarly to urine leakage it is a relatively large presentation, it can be dealt with effectively in primary care, there is a lack of public knowledge about how to access primary care out of the GP setting, there is an opportunity for effective use of pharmacy to deal with first presentations
Erectile dysfunction: chosen because it a medium volume of presentations (10 – 15%), could be better dealt with in primary care or patients could self-manage, pathways are not well known or defined
Undiagnosed flank pain: chosen because normally patients are referred straight to CT scan, there are significant regional variations, it takes up a significant amount of repeat appointments in general practice
Initial Focus Areas
Once the symptom profiles had been described and ranked, the DHI team led two round-table discussion groups. Each group focussed on two symptoms and mapped the current pathways highlighting the general high level challenge areas for each symptom. The DHI team sketched out current system level maps and noted down areas of best practice, variations and, importantly, challenges areas. The initial challenge areas identified by the group were.
Repeat appointments: it was identified that there is a culture in Urology of making default repeat appointments for patients when in many cases this is not required. Some patients are seen periodically for up to five years in repeat appointments in primary and secondary care environment. Addressing this issue would have a significant impact on the capacity of the system and free up appointments for patients where seeing a consultant is more valuable.
Infrastructure: through the mapping of current best practice it became clear that a ‘one stop shop’ model for testing is a gold standard for service efficiency and quality. However, one stop shops have specific resource requirements and certain infrastructure needs for them to work. Without the right physical space or purpose built facility it is very difficult to co-ordinate tests and therefore exploit the one stop benefits. Developing models that do not rely on the right physical infrastructure and are based on the reality of different settings could support change and have significant impact on services.
Succession planning: while not something that is immediately associated with pathway improvements, lack of planning for staff change can have a detrimental effect on a clinical area especially when teams change and skills and knowledge is lost.
Vetting and signposting: each symptom profile map raised the issue of signposting people onto the correct pathway. It was felt a review of ‘who’ is control of vetting and signposting at each phase of current pathways would help understand who the most appropriate person would be and potentially improve current resource use.
Education and knowledge: many Urological presentations could be dealt with either in a community setting or by patient self-management. Currently this is not the case, the challenge is getting the right information to patients so they are aware of what they can do before presenting to a GP.
Now that the Urology group have identified some high-level challenge areas, the next step will be to apply detailed scrutiny to the current pathways the group sketched out in this first workshop, focus in on the finer detail of what needs to happen to make an improvement, and crucially define what success will look like. This will take place in the next Urology workshop later in May.
Urology Workshop Two
On Thursday 31st May, the Scottish Access Collaborative Urology Specialty Group met for a second time with the Digital Health and Care Institute’s (DHI) design team to continue their work on service improvement opportunities. Following a successful first workshop where the Urology group debated and decided on four key symptoms to focus on, the second workshop would continue the previous work and map out some more common pathways for the key symptoms, highlight the issues with current pathways, and crucially for this session start to identify the opportunities for improvements. The day began with a quick recap of the work from the first workshop and a refresh of the aims of the Collaborative. For this workshop the DHI team had brought with them some research in the form of posters of patient comments regarding the Urology services in Scotland. The quotes highlighted the Urology service positives and negatives from the patient perspective, and the Urology team where encourage to spend the first 10 minutes of the day reading through what people had said in an attempt to bring the wider patient voice into their thinking.
Once the whole group had familiarised themselves with the patient comments, they broke away into small working groups and each spent some time describing a system map for an assigned symptom. In the previous workshop the group worked in detail on the Visible Blood in Urine and Urine Leakage symptoms. In this session, they completed the mapping of: Erectile dysfunction. Chosen because represents a medium volume of presentations (10 – 15%), it could potentially be better dealt with in primary care or patients could self-manage, and pathways are not well known or defined. The group also created a map for Undiagnosed flank pain. Chosen because normally patients are referred straight to CT scan, there are significant regional variations, and it takes up a significant amount of repeat appointments in general practice; and began to map for Lumps and Bumps.
Once the system maps where complete for all the prioritised symptoms, the groups began to apply detailed scrutiny to the current pathways, focussing in on the finer detail of what needs to happen to make an improvement, and crucially defining what success will look like. To do this the groups developed more detailed maps that zoomed in on particular routes symptoms can follow through services, focussing on routes that offered service improvement opportunities, and by doing so pin pointed the main issues for Urology. Through this exercise the group honed in a few key issues.
1. Quality of referrals: can GP be better supported to help make only appropriate referrals with suitable guidelines?
2. Quality and availability of information: for conditions like mild Urine Problems and Erectile Dysfunction what can be done to support more primary treatment and patient awareness of options?
3. Appropriate referral and consultation: in the case of some Urine Problems, for example, pharmacies could refer direct to Urology but only GP can do it currently leading to unnecessary appointment. Who are the right people to be seeing patients and making referrals?
4. Rate of referrals: in the case of Urine Problems there are many referrals into secondary care when many cases could be dealt with in primary with first line testing and treatment. Can more treatment be tried / started in primary care.
5. Improved Ultra Sound testing pathway: currently Ultra tests are referred out of primary yet there is an opportunity to conduct nurse led Ultra testing that would prevent some transition into secondary for patients.
Defining Opportunities: then and now
Once the issues had been identified, each working group looked in even more detail at what is happening now, and made some suggestions of what could change for the future to make improvements and address issues. Using a pathway map template designed especially for the workshop, the groups defined some step changes for current pathways, some suggestions for role changes, and some suggestions for pathway remodelling.
1. patients with urine problems are often brought back into secondary for routine follow up appointment but with no added value. The suggestion was for an opt in patient led route for follow that would reduce the number of non-value added appointments.
2. also with urine problems patients are often referred directly to Urology for assessment, blood testing and treatment, yet this could be done in primary. The suggestion was for supported pathway in primary for first line treatment.
3. a significant proportion of patients travel to Urology unnecessarily after vetting when a phone call would be sufficient. The suggestion was for a telephone consultation step in the Urology pathway that could deal with this section of patients, prevent unnecessary travel, and free up some consultant capacity.
4. it is common practice for ultrasound scans to be performed out of primary care, although there are some examples of nurse led ultra sound scans in primary care. The suggestion was that ultrasound could be brought into primary care setting, and combined with referral criteria for GP’s and a telephone consultation service. This saving unnecessary Urology appointments for patients, reducing patient travel and freeing up some consultant capacity.
Later in May the Urology group will meet for the third and final time with the DHI design team. The aim of the final workshop will be to scrutinize the proposed improvement opportunities in detail, cross referencing with the Core Principles of the Access Collaborative, and prioritising which to take forward. Then the group will begin to flesh out what needs to happen next and who needs to be involved to move opportunities on for further detailing, and closer to implementation. In the meantime, the DHI team will visualise the current suggested pathway improvement opportunities and map the proposed changes onto current paths.
Urology Workshop Three
Recently the design team from Digital Heath and Care Institute met for the third and final time with the Scottish Access Collaborative Urology specialty group to complete their initial work on urology service improvements. The main aims of the series of three design workshops are to uncover some key areas for focus for urology service improvements, find and share current best practices across current service provision in Scotland, and to develop some ideas for service improvements to take forward for potential implementation. Having already arrived at some service improvement ideas through workshops one and two, this third workshop was an opportunity for the group of urology specialists to review and refine those ideas into recommendations for the future.
The first recommendation to be reviewed was for Dedicated Vetting as part of clinical services. Vetting is vital to reduce the number of unnecessary presentations in secondary care and improving patient experience. Investing in dedicated time for vetting by a senior decision maker can save time and resource down the line, and make patient journeys more efficient. Ultimately it comes down to the quality of information in terms of referral and having clear pathways to match the information too. If the information is good and the pathways are clear, then vetting can be much more effective.
The group then discussed the idea of a Virtual / Telephone Clinic. In this scenario, certain identified cases can be followed up by a telephone / virtual consultation to keep people away from secondary. The point of the telephone consultation is it can screen who needs to come into clinic and who does not. In the case of benign urology (a large number of cases), virtual clinics can check with patients if they want something done or not over the phone before they come to the hospital. The group recognised it is a huge amount of work to run a virtual clinic, it doesn’t take away volume but it can stop patients coming in to clinic, saves money on travel and will give more clinic time for complex cases.
Next on the list of recommendations was changes to GP referral guidelines and supports. The group discussed how there needs to be more options for GPs to ask the right questions, for example does the patient want an operation or not in the case of benign urology. There is an opportunity to utilise more primary services and provide more signposting support for GPs’. The group highlight some issues with GP guidelines. First is keeping guidelines current, they aren’t the resources to keep guidelines updated. Second was the local variations, the majority of guidelines can be national but local provisions vary and are bespoke. Finally, sometimes referrals are not completed by GPs and so any SCI gateway guidelines are not even seen.
Patient Led Follow Up was a significant area for improvement. Unanimously it was agreed routine secondary care follow up should never be the option, if the symptom can be managed then the patient should be given the right support to do that, including a treatment plan with information of good quality, and a point of reference not necessarily a GP or consultant. The idea of Virtual / Telephone Review Clinic was discussed. Why should patients travel for 2 or 3 hours for a 5-minute follow up appointment? Generally, it was agreed that by default patients get a treatment plan, supported by community or pharmacy, but patients should never come back to hospital unless necessary.
Another significant area was Direct Access to CT Scans before consultation. The idea is direct request from GP for a low contrast CT scan, for patients with flank pain and suspected stones. Currently patients are sent to the clinic, only to be told that they are going for a scan when the referral could have come from primary. Changing to the direct access approach will not affect the volume of CT scans, but it will affect the number of people going to clinics first, improving patient experience. The group recognise this is an idea that needs to consultation with radiologists, and if implemented needs good quality guidelines and support.
Finally, there was a general point made about the quality and timing of information and contact with patients. Information for patients early in the process can have huge impact on their journey and health care resources. In the case of Virtual Clinics simple things like scheduling calls properly, making sure patients know who will be calling, the number that will be calling them and the time of the call can improve efficiency. The group discussed Keep In Touch Calls for patients with long waits as an opportunity to keep on top of the symptoms and check if they are deteriorating and if need be escalated up the list, or they just keep the patient informed that they have not been forgotten.
The next step is for the DHI team to compile the recommendations into the Urology specialty group report which will be published here on the Scottish Access Collaborative website.
A guest blog by Mr Steve Leung MD. Consultant Urological Surgeon, Honorary Senior Lecturer (St. Andrews University)
Following the completion of their initial three workshops, we ask that participants from each specialty group who attend the SAC board to discuss their specialty with the wider group of stakeholders, reflect on that experience and write a short blog to share that experience with the wider group. For Urology, Dr. Steve Leung was in attendance at the recent SAC board and has written this piece.
As you know, Gynaecology and Urology were the first 2 specialties to report. We were both allocated 15mins each to discuss the output of our workshops. This is not much time to condense the work we did over 3 workshops. My slides did not arrive at the meeting so I ended up giving a verbal report without slides. In a way, this was good as it had the members focused on the narrative provided by the key findings in the report. There were already some common themes between the 2 specialties presented and the chairman picked up on the commonality - such as time for high quality vetting, clear, accessible guidelines and opt-in follow up after discharge.
I was asked what my "top 3" high impact actions would be. The time for high quality vetting, clear accessible guidelines and direct access to diagnostic tests made my top 3.
My impression is that they are looking for commonality in some of the issues so that this can be a work stream across many specialties. And in doing so, perhaps the methodology for tackling some of these issues can be similar across specialties
The SAC Urology Report is available to download through the Urology Final Report Repository.