Analysis carried out by The Health Informatics Service (THIS), which is hosted by the Calderdale and Huddersfield NHS Foundation Trust (CHFT), found that in May 2021 patients from a minority ethnic background were waiting almost eight weeks longer, on average, than white patients for a ‘priority two’ (P2) operation – which NHS guidelines state should be treated within a month of prioritisation.
We also found patients from the most deprived communities were waiting 8.5 weeks longer than those from better off areas, prompting leaders at CHFT, which runs Huddersfield Royal Infirmary and Calderdale Royal Hospital, to turn to THIS for a digital route into solving the issue.
Digital interventions created and implemented by THIS through collaboration with the Trust’s executive team, performance analysis staff, general managers, senior clinicians and appropriate information staff resulted in waiting lists for ethnic minority patients dropping by almost five weeks on average within six months, while those from deprived areas saw the wait cut by an average of six weeks.
Since then, there has been a dramatic improvement in waiting times and the digital prioritisation markers are being applied to patients with other characteristics, such as learning disabilities, frailty, obesity and mental health issues.
All-encompassing approach to tackle inequality
Digital health solutions delivered by THIS for CHFT have helped to make it one of the most digitally mature Trusts in England, and as such, digital solutions are the golden thread running through everything we aspire to achieve in conjunction with CHFT, to benefit clinicians and patients alike.
Calum MacIver, our Corporate Information Manager, explains:
“Our Information Team started pulling together figures from our data warehouse into the Trust’s business intelligence platform, referred to locally as Knowledge Portal+ (KP+), using Qlik Sense and added in nationally available data, such as population information, deprivation and census data.
“This led to a larger, all-encompassing health inequalities model, where markers were attached to patient data at source. It created a new method of looking at waiting lists, that didn’t just examine total numbers but started to factor in the data from the perspective of the different patient characteristics, and it has created a new culture within the Trust and THIS, where we take account of inequality in everything we do.”
The proactive approach led to a larger, more ‘all-encompassing’ health inequalities model containing:
- Inpatient and day case activity.
- Outpatient activity.
- Emergency Department (ED).
- Waiting lists.
- Pathology.
- Cancer data.
We then created a similar data structure with health inequality markers attached to the data at source to include:
- Index of Multiple Deprivation (IMD) deciles.
- Ethnicity.
- Frailty.
- Learning disability.
All of this information was shared via the trust’s KP+ system with CHFT’s executive team, performance staff, general managers, senior clinicians and appropriate information staff throughout the Trust.
With the waiting time discrepancies clearly illustrated, it led to dialogue between CHFT leaders and senior representatives from commissioning organisations, local authorities, and senior clinicians within the Trust and in the community.
The new method of looking at waiting lists did not just examine total numbers but factored in the data from the different ethnic groups, IMD deciles and those with other characteristics. A clear aim was to facilitate a reduction in these discrepancies whilst bringing down overall waiting times.
How the improvements were achieved
By March 2022 the average disparities had been reduced to a matter of days for both groups. This was achieved through the following, extensive, set of measures:
- Review and improved data quality.
- Analysis of waiting time data.
- Reviewing waiting times across pathways to establish points of divergence.
- Dedicated contact team established for scheduling patients.
- New pathways being developed.
- Weekly inclusion of data in leadership briefings in addition to internal and external engagement.
- Clinical reference group established and dataset by specialty and consultant developed.
- Specific tracking to ensure equity of waiting time for learning disability patients.
- The Board of Directors agreeing additional prioritisation for learning disability patients.
With the latter two points in mind, we have introduced:
- Individual patient planning.
- Dedicated vaccine clinics.
- Children’s waiting list validation and prioritisation.
- A new care pathway in the Electronic Patient Record (EPR).
- A new checklist in children’s services to improve consistency and accuracy.
- A new dashboard covering a range of metrics.
- A flag in EPR allowing identification of patients on referral.
- Individual priority pathways for patients with learning disabilities so this change is sustained.
Another measure of success is that scrutinising health inequalities among all vulnerable categories – not just ethnic minorities and areas of deprivation - such as combining data with national data, and for example, data for over-70s and those with learning disabilities - has created a new culture within CHFT and THIS whereby inequality is factored into everything we do.
We are now exploring:
- Cancer activity profiles and waiting list addition trends.
- More closely involving clinicians in the data analysis process.
Winning plaudits and attracting attention
Our work on eradicating health inequalities has attracted attention from other trusts such as University Hospitals Birmingham NHS Foundation Trust, NHS Herefordshire and Worcester CCG and Rotherham NHS Foundation Trust.
NHS England’s improvement body asked us to present at an NHS Expo in Liverpool, where we shared knowledge we’ve acquired with colleagues from across the UK, while Dr Graham Walsh, the previous Chief Clinical Information Officer at CHFT, has requested the help of the Information Team for an Academic Health Science Network (AHSN) presentation in Dubai.
And the work done with CHFT has been included as an exemplar case study in the NHS Healthcare Inequalities 2022/23 planning guidance advisory note, which says:
“The analysis of the data contributed to the inequalities being cut significantly... other systems could adopt a similar approach, making use of the Health Inequalities Improvement Dashboard (HIID).
“The total waiting list size, including disaggregation by deprivation and ethnicity, as demonstrated by this work should be included in the Key Performance Indicators to be assessed”.
The West Yorkshire Integrated Care Board has put together a business case to provide a project management resource to facilitate the sharing of lessons learned and supporting similar implementations were required across secondary care trusts.
This business case outlines a proposal to address the inequalities and variation in health care for people with a learning disability following the pandemic, focusing on the Referral to Treatment (RTT) and waiting lists and Did Not Attend (DNA) data across the Integrated Care System (ICS) from a secondary care perspective.
Amanda McKie, the Matron Lead for Learning Disabilities (Adults) at CHFT, says:
“All the hard work that has gone into ensuring the learning disability flag is built into our KP+ dashboards, to make it happen, is remarkable!
“We have given several presentations to trusts across the country since then. Regionally, I have been approached by local trusts on how we did this and our methodology. Some trusts have adopted a similar approach.”
It is anticipated that the transferable model developed at CHFT can be adopted by Acute Trusts within the ICS and thus play a significant part in the ICS becoming an exemplar system for people with learning disabilities.
Calum MacIver adds:
“A representative from the Information Team now attends monthly meetings of a learning disability group to share knowledge and gain greater understanding from key stakeholders.
“A further ripple effect is work now taking place within the Trust to specifically look at inequalities among asthma sufferers, and a community-based project is working with primary care stakeholders in a highly deprived area of Huddersfield, again to share knowledge and gain better understanding to influence positive health outcomes in the area.”
Further enhancements include the development of a prioritisation matrix – that applies a vulnerability score at an individual patient level when considering their care pathway, and increased informatics and project support dedicated to health inequalities.
Furthermore, the work has helped the Information Team tasked with quantifying inequalities to better understand the workings of the Trust and its clinical priorities. Different groups no longer work in silos, and there is greater shared knowledge and expertise among all involved.
Striving for further improvement
Our work is ongoing, and our next steps include:
- Continuing to ensure health inequalities is considered fully in the regard of hospital reconfiguration planning.
- Considering health inequalities when procuring independent sector provider-delivered activity.
- Developing and agreeing a many faceted prioritisation matrix – that applies a vulnerability score at an individual patient level when considering their care pathway.
- A focus on homeless patients and frailty.
- Increased informatics and project support dedicated to health inequalities.
- Developing a case for learning disability care navigators.
- Working with referrers to ensure there is a learning disability flag on every relevant referral.
Innovation and collaboration
In addition to CHFT, The Health Informatics Service enables new, empowering, efficient and secure communications and IT services for clients including other health trusts, GP practices, laboratories, hospices and care charities. For more information vist the THIS website.
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