Workloads at Casualty and outpatients - The Times - 4/12/2004

Casualty Department kept busy

A total of 65,667 patients used the Casualty Department in the first seven months of this year. The figures were 111,034 for the whole of last year and 109,189 for the previous year.

The figures were given by Health Minister Louis Deguara in reply to a question by Jason Azzopardi (PN).

Patience at outpatients
Vanessa Macdonald
Workload at St Luke's Hospital outpatients
Total New cases Follow-ups

279, 060 63, 413 215, 647

284, 063 65, 866 218, 197

247, 515 65, 454 182, 061

250, 494 62, 936 187, 558

Over the last two years, the management of St Luke's Hospital has applied itself to improving the quality and efficiency of the Outpatients Department.

Stephanie Xuereb, a principal medical officer with a masters degree in public health, has been working on improving the department since September 2002 and the efforts are starting to show results, although much remains to be done.

The pressure on the department is clear when one looks at hospital statistics. In 2003, 62,936 patients were referred as new cases while 187,558 patients attended the Outpatients Department for a follow-up appointment. This averages at about 1,000 patients per day.

"Easing the pressure on the Outpatients Department was tackled in various ways. The first was to check the appropriateness of the timing of outpatient appointments, the idea being to rearrange the scheduling system so that the amount of time that patients have to wait to be seen by the doctor will be cut," Dr Xuereb said.

"We look at both the time of the appointment and the actual time when patients are seen. A lot of people, especially the elderly, have a habit of turning up as soon as the department opens at 7 a.m. So by 10 a.m. they complain that they have been waiting three hours, even though their appointment might have been for 9.30 a.m."

In the past, block appointments were given for time-slots, rather than specific times.

"I know that some clinics used to tell 10-15 people to come at 9 a.m. with another batch told to come at 10 a.m. and so on. This is obviously impossible."

The scheduling system was an obvious place to start. Appointments are being rearranged with more realistic times being given, to better manage patient flows and decrease patient waiting times.

"We have set about changing the appointments already made for the next six months to the new appointment times, for example in the orthopaedic clinic, but as you can imagine, it is very labour-intensive and it will take a number of months to amend all the clinics to the new scheduling times.

"Sometimes, the patients are held up because they need tests in other departments, like X-rays or some other form of radiological investigation. We are trying to see how to speed things up, although it is proving to be very difficult due to space and time constraints," Dr Xuereb said.

Another area that was dealt with was to ascertain whether all the appointments were actually necessary. Unfortunately patients are referred to the Outpatients Department for conditions which could easily be managed in the community. Involving GPs would relieve the Outpatients Department but this is not always possible especially with patients who do not have a specific GP.

"People just keep coming back, even though they have completed their treatment. Although many clinicians agree that there is no need for some people to keep on coming indefinitely, discharging patients into the community is not always possible."

There is also a psychological element: Many patients like going to the hospital and do not want to be discharged, even though the doctors feel that the person is cured. In the case of chronic conditions, once the patient's condition has been stabilised, further long term monitoring can be carried out by the GP.

The health centres are already being given a greater role in spreading out the load. A number of consultant clinics are held there, including diabetes, well-woman and well-baby clinics.

The hospital is looking at the possibility of moving other clinics away from St Luke's, the main contender being the busy anti-coagulant clinic, for people taking the blood-thinning drug warfarin.

The congestion at the department is one facet: Another is the time it takes to get an appointment.

"Follow-up appointments are given depending on clinical requirements, irrespective of whether the clinic on that date is already full or not. And even new patients who need urgent treatment are added to the list. Usually about eight to nine per cent are added on at the last minute," she said.

Very few clinics can give appointments within four weeks, with the majority of clinics having waiting lists between four weeks and three months. This compares quite favourably with the British NHS targets, where again similar problems of matching demand to resources exist.

There are some extremely busy clinics like gastroenterology and orthopaedics, which have a six-month waiting list. The latter clinics are now using a system of triaging - filtering according to the medical urgency of the case, as is done at the Accident And Emergency Department. This relies on getting a comprehensive referral note from the GP.

"This way, the appointment is given depending on the case. Someone who has had back pain for five years is not as urgent as a young person being referred with a lump, for example."

As with all things, the sword is double-edged. While the hospital is doing what it can to improve, patients can also do their bit. The biggest problem is people who fail to show up for their appointment.

"We studied a two-week period and found that 30 per cent did not show up! We analysed why people do not come. It varies from their problem having been solved, to having seen a private doctor, or just plain having forgotten."

The longer ago the appointment was made, the higher the level of no-shows.

"It is more likely for the condition to have cleared or for the person to forget all about it, especially when they have more than one clinic to attend."

Dr Xuereb hopes to raise more awareness of the need to cancel unneeded slots and make people more aware of the impact of booking outpatient clinics and then not turning up.

Considerable time is spent preparing medical records and chasing up test results.

"But the most important thing is that they are tying up slots that could be given to someone who really needs it. It would be so helpful if people could call the main reception to cancel."

The department has considered calling patients a few days before to verify whether they would be attending, or sending letters reminding them of their upcoming appointment, however the cost would be considerable and this option has been discarded for now.

"We will probably have to consider this if the trend continues."

To cancel appointments, patients may call at the Outpatient Reception on 2595 1362, 2595 1249 or the main reception on 2595 1522, 2122 4518. The best time to call is between 2.30 and 5 p.m.

The British alternative
The British National Health Service is tackling its long waiting times for outpatient appointments by focusing on general practitioners.

It was recently announced that GPs would get budgets as from April 2005 to be able to commission services such as MRI scans.

It is envisaged that many of the UK's 45 million outpatient visits could be handled by the primary health care sector as a result of this voluntary scheme.

The British Health Minister, John Hutton, said recently that many of the follow-up outpatient appointments, which account for two-thirds of the total, did not need to be done by specialists in hospital.

The pressure on the outpatients department is clear when one looks at hospital statistics. In 2003, 62,936 patients were referred as new cases while 187,558 patients attended the Outpatients Department for a follow-up appointment.

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