Achieving 18-week waiting times in elective hand surgery

Abstract

Objective: The Department of Health proposed an 18-week referral-to-treatment time (RTT) as a measure of high quality healthcare, to be achieved by December 2008. In 2007, referrals for elective hand surgery, to the Plastic Surgery Hand Service, were either direct or indirect. Direct referrals were from the general practitioner (GP). Indirect referrals were from other specialties, to which patients had been initially referred. We audited the RTT in elective hand surgery patients to see if 18-week waiting times could be achieved.

Design: The RTT for 152 patients who had elective hand surgery in 2007 were audited prospectively and retrospectively. After the initial audit, managers responsible for the 'Choose & Book' (CAB) GP referral system, managers responsible for 'Action on Orthopaedics' and colleagues who referred, were contacted, to explain the difficulties in meeting the 18-week wait target. The audit cycle was repeated prospectively in 2008 with the audit of a further 94 patients.

Setting: This audit took place in a district general hospital, in the United Kingdom.

Main outcome measure: The main outcome measure was referral-to-treatment time.

Results: The mean RTT for direct referrals decreased from 15 to 12 weeks and that for indirect referrals decreased from 43 to 24 weeks (p < 0.0001). The difference in the average RTT for direct and indirect referrals remained statistically significant (p < 0.0001), in both audit cycles.

Conclusions: The attempts to reduce the RTT, in both groups of patients, did not decrease the average RTT for indirect referrals, to within government targets. Increase in GP awareness of the limitations of the CAB system and availability of local hand surgery services, may help to reduce inappropriate referrals. However we are aware that a multispecialty approach is required to ensure that hand surgery referrals are passed on to plastic surgery as soon as possible.

Figure 1

(a) Histogram of elective hand surgery cases in the initial clinical audit; (b) histogram of elective hand surgery cases in the clinical re-audit

Figure 2

(a) Graph of percentage of referrals and the referral-to-treatment times before information campaign; (b) graph of percentage of referrals and the referral-to-treatment times after information campaign

Figure 3

Graph shows a comparison of the referral-to-treatment times for direct and indirect referral patients before and after instituting changes to improve the indirect referral pathway. Columns show the mean RTT and error bars indicate the standard error of the mean. The dotted line shows the 18-week RTT target