Getting It Right First Time (GIRFT) Initial Report IMPT Council
Author: Jason Watson Date Report: 02/07/19
IMPT GIRFT Group; Richard Eggleton, Stefan Edmondson, Edward Malton, Barry Edwards & Mark Cutler, Mathew Pilley, Jason Watson (6 units)
Introduction
Getting It Right First Time (GIRTF) is a national review of NHS surgical and medical hospital specialities. It started with orthopaedics in 2012. The review was commissioned to look at key areas, to examine ‘best practice’ and try to improve patient outcomes within the resources of a modern NHS. They visited over 200 hospitals, gathered data and listened to challenges and potential solutions. The data allowed the group to make recommendations that have saved the NHS over £200 million pounds to date.
GIRFT is an exercise in an era of unprecedented financial challenges so savings are a part of this process. Trying to make efficiencies in service provision and procurement. The process is also examining what current services look like, which services function better than others. Who is delivering the best care? How do we help those services that are not working well to improve?
The other GIRFT reports across multiple specialities have focused on developing networks regionally to make savings and provide less duplication, or centralising services to improve outcomes for patients by developing and focusing on what individual specialist units are good at, and do more of it.
Maxillofacial & Oral Surgery
The provisional review into Maxillofacial surgery was published in November 2018. The GIRFT Lead for Maxillofacial services is Maire Morton, a Consultant Maxillofacial Surgeon. The review found considerable variation in the surgical services provided and the quality of those services and outcomes for patients. The Maxillofacial review estimates savings of up to £25 million pounds a year across the specialty.
Laboratory services are briefly mentioned in the revue, but the GIRFT Team contacted the IMPT as they were keen to get a focused, profession-supported view on services.
How do we measure the success of our services? Is it numbers, financial parity or actual patient quality of life improvements? The review discusses the development of outcome measures across the services. It may be that we have to consider how we look at our own services in terms of success or failure. A key measure for us that we are starting to get a grip with is audit. A national approach would be useful to create bench-mark data and gauge performance.
IMPT Involvement to date
There is to be a review of laboratory services in England. The IMPT Chairman Barry Edwards met with Maire Morton to discuss the services we provide and the role the profession should play in examining our practices. Any review has to understand the complexity of our roles and services and that we work across many disciplines.
IMPT Council members were appointed to work with GIRFT to undertake this task.
The initial GIRFT report recognised variation in laboratory services across the country in provision of services (large gaps in specialist coverage) and type of services (variation) and investment in the laboratories (new technology). The key questions the initial report and subsequent discussions raised were; What is a maxillofacial laboratory? What does it look like now? What should look like in 10 years? Where do we need them to maximise service provision for patients and surgical specialities?
6 themes that GIRFT have already recognised within Maxillofacial Surgery are:
- Data Quality & Collection
- Performing Dento-alveolar in appropriate settings
- Improving efficiency through improved care networks
- Optimised Secondary Care pathways
- Litigation
- Procurement
3 themes applicable to IMPT members:
- Data Quality and Collection; Electronic Staff Record (ESR); Clinical episodes and cost coding)
- Improved Care Networks; Regionalisation & Hub & Spoke’ approach
- Procurement (focus on 3D printing services)
The IMPT steering group developed a pilot questionnaire to collect data in the 6 units to better understand the 3 themes.
Data Quality & Collection
ESR & Staff groups
The IMPT already has a project on the way staff jobs are recorded on ESR. We are working with NHS Digital (2017-) to make job coding clearer so we all can use titles on ESR that are applicable to our roles. They are currently not fit for purpose. The current Occupational Coding Manual (12/18- update 03/19) has finally recognised Reconstructive Science as an Area of Work. Previously there was nowhere for Clinical Scientists in Reconstructive Science. However the volume still lists MfP under Dental Technician Maxillofacial S4R & Maxillofacial Technologist/Prosthetist U4J. These are non-scientist level codes (undergrad scientist level) and are outdated.
The 6 units in the pilot questionnaire were asked about their staff coding. The units were of differing size (Regional/District Hospitals); staff between 1-8 MfP (excluding Trainees). In the 6 units, staff were listed in various groups, some in the old Scientific & Technical (T codes transferred to S codes; estates etc.) and Healthcare Science U codes. If we don’t code consistently then we will have no idea of our workforce needs.
Finance & Clinical Episode Coding Variation
The IMPT pilot showed variation in both clinical outcome and costs/income. Generally the costs were gathered from an external source, and set up in cost bands (0-5 bands established). Clinical Commissioning Group’s (CCG) were invoiced with different tariffs, and generally some sort of tariff device exemption was in place. 1 unit had no external income and relied solely on internal trading.
Income variation
Variation in the income generated from external sources differed. The basic data included:
- Tariff/Band charges from £108-£6467 (per item in the 5 bands)
- Externally generated total income (2018 financial year) range - £6813 - £652,190 pa
- data collected monthly/returned to Finance; some Service Level Agreements (SLA with other Hospitals/CCG in place)
We asked for data on specific items (n=8; limited for ease of collection), examples of the range of costs based on income Band for each item:
- Surgical cover-plate £108 - £1611
- Adhesive nasal £855 - £2756
- Single Jaw BSSO £0 - £789
Each department gave different costs for each item. This is a simplistic approach but does allow variation to be examined and discussed.
Clinical Episode Coding
Outpatient outcome codes are important to highlight our clinical input to services. Each of the 6 hospitals had different approaches to coding out patient activity. The Hospital Episode Statistics (HES) have some limited applicable codes available for our use, however these were general and in most cases the patient was adapted to fit a code rather than it represent the actual clinical work undertaken. Other hospitals had locally agreed codes or used just a general ‘new’ and ‘follow-up’ formula. We asked for codes apportioned to specific MfP clinics and the range of appointments recorded (2018) ranged from 7 – 1102 appointments.
Improved Care Networks
Regionalisation has already started in our services. Laboratory services have adapted in some regions to the establishment of surgical initiatives for example in major trauma & cleft services but the respondents to the questionnaire recognised there still needs to be further development.
Few truly ‘Hub & Spoke’ services exist. The IMPT working group thought a likely scenario would be a hybrid version similar to the airline model of ‘Hub and Hybrid Spokes’. Where we have linked but separate services (like code sharing) on different sites but share resources such as centralised 3D printing units. The regional laboratories would recognise that they each have diverse specialist expertise. So they would refer to each other. This would help maintain local and regional services by allowing access to the larger centre’s resources.
Others Issues Identified
The review showed a lack of local & national training places. Only 3 of the 6 units had trainees on the national training programme (STP).
Next Steps
Further work for IMPT GIRFT group will involve contacting you directly and also the GIRFT committee contacting your Trust. We envisage:
- Highlight the importance of the work to IMPT members future
- Stage 1: ESR current coding improvement; then disseminate IMPT guidance to members and all NHS HR departments
- Stage 2: Develop questionnaire to examine in detail specific issues (further pilot) & draft a focused version
- Opportunity for discussion at the IMPT Congress Swansea 2019 meeting
- Work with BAOMS & the Department of health GIRFT office
- Stage 3: Questionnaire to all units; GIRFT & IMPT representatives to visit 20-30 units in England
This is not a process we will be able to opt out of. The Maxillofacial surgical review has already been to most hospitals gathering data on you and your work. This is our opportunity as a group to highlight our work and the extraordinary staff and opportunities the NHS has by developing and supporting our work force.
Further information:
www.baoms.org.uk/about/news21/getting_it_right_first_time
www.gettingitrightfirsttime.co.uk/surgical-specialty/oral-and-maxillofacial
www.digital.nhs.uk/data-and-information/areas-of-interest/workforce/nhs-occupation-codes
