BMJ  2003;327:1147 (15 November), doi:10.1136/bmj.327.7424.1147

Quality improvement report

Booking patients for hospital admissions: evaluation of a pilot programme for day cases

¹ Health Services Management Centre, University of Birmingham, Birmingham B15 2RT

Abstract

Problem NHS patients requiring elective surgery usually have to wait before being treated and are usually told when a date becomes available.

Design 18 month pilot programme to enable day case patients to book date of hospital admission at time of decision to operate.

Background and setting 24 pilot sites in England with relatively short waiting times and some experience of booking appointments.

Key measures for improvement Proportion of patients with booked or "to come in" date during and after pilot programme, proportion not attending for admission, and proportion waiting 6 months. Comparison of pilot sites with non-pilot sites.

Strategies for change National Patients' Access Team established to help pilot sites enable patients to book admission dates. Provision of £9.9m to pilot sites to employ project managers, purchase equipment, buy extra time from clinical and other staff, and invest in information and communications technology.

Effects of change Proportion of patients with booked or "to come in" date increased from 51.1% to 72.7% between end of March 1999 and end of March 2000, and then fell to 66.2% by end of March 2001. Over the same periods, the proportion of patients waiting 6 months fell from 10.9% to 10.5% and then increased to 11.9%. The proportion of patients failing to attend fell from 5.7% to 3.1% between the first quarter of 1999 and the first quarter of 2000, and then increased to 4.0% in the first quarter of 2001. Pilot sites varied widely in performance during and after the pilot phase. Pilot sites had higher proportions of patients with booked or "to come in" date than non-pilot sites at end of each period.

Lessons learnt Increasing the proportion of patients who book their date of hospital admission is possible, but there are difficulties in sustaining this. Several factors facilitated or hindered the implementation of booking, and the roll out of the programme across the NHS is seeking to incorporate these factors.

Background

Patients in the NHS requiring elective surgery have usually had to wait before being treated. When a decision to operate is made, patients are placed on a waiting list, and they are contacted when a bed and theatre time become available. At this stage, they have what is known in the NHS as a "to come in" date. Successive governments have sought to reduce the time patients wait for surgery as part of a policy of improving access. In the past five years, this policy has also promoted convenience by offering some patients the opportunity to book the date of admission to hospital at the time of the decision to operate.

Booking the date of admission is not new,^{1 2} but, apart from one influential but unsuccessful example,^3-5 it has mainly been confined to the efforts of individual surgeons. The establishment of the National Booked Admissions Programme in 1998 was the first concerted attempt to introduce booking across the NHS. The first wave of the programme involved 24 pilot sites (each comprised of one or more hospital trusts) from different English regions, and ran from October 1998 to March 2000. The programme was subsequently expanded with the aim of booking all day case admissions in the NHS by March 2004 and all consultant services by December 2005.^{6 7}

All of the pilot sites started with maximum waiting times at or approaching six months and some experience of booking appointments. These favourable characteristics were intended to enable the sites to show what could be achieved with the additional resources they were allocated and the support of the "National Patients' Access Team." The pilot sites were not chosen to be representative of the NHS as a whole. This paper reports on an evaluation of the first wave of the programme.⁸

Key measures for improvement

We assessed the proportion of patients waiting for surgery at the pilot sites in the quarters ending March 1999, March 2000, and March 2001 who had an admission date booked. We chose the first quarter of 1999 as the baseline because not all the pilot sites were able to start booking at the outset of the programme in October 1998. Data from these three periods allowed us to assess progress during and after the pilot phase, and the use of data from the same quarter in each year allowed us to control for seasonal factors. We also analysed the impact of the programme on the proportion of patients failing to attend for their operations and the proportion of patients waiting six months or over, as admission booking was expected to reduce these numbers.^{9 10}

We gathered activity data from the pilot sites using the same definitions as those used in the central statistical returns for the NHS. This enabled us to compare the performance of the pilot sites with that of other hospitals in England. Pilot site data include all the activity for those consultants who were active in the programme during the quarter ending March 2000. We supplemented the analysis of activity data with a questionnaire survey of pilot managers on their experience, a survey of consultants in three pilot sites that we chose for more detailed study, and over 250 interviews with staff involved in the first wave of the programme.

Statistical analysis
We analysed the programme level changes in proportions reported in table 1 using the weighted paired t test based on the logistic transformation of clustered (pilot level) data.^{11 12} For analysis of changes in proportions for individual pilot sites (see extra tables on bmj.com), we used the standard probabilistic approach, which assumes the conditions of normal approximation are met and samples are independent and large.¹³

View this table: [in this window] [in a new window]   Table 1 Day case admissions among 23 pilot sites in the first wave of the National Booked Admissions Programme, 1999, 2000, and 2001. Values are percentages (denominators) of patients unless stated otherwise

 

Strategies for change

The intervention used in the programme was the establishment of the National Patients' Access Team to work with the pilot sites on redesigning services to enable patients to book their date of admission. The Department of Health allocated £9.9m to support the first wave pilot sites, and these funds were used to employ project managers, purchase equipment, buy additional time from clinical and other staff, and invest in information and communications technology. The National Patients' Access Team organised monthly meetings for project managers and other staff to enable them to be trained in service redesign skills and to exchange experience with their peers.

Each pilot site set up project management arrangements involving a project manager or project team under the direction of a steering group. In some sites there was a strong commitment to the project through the close involvement of chief executives of hospital trusts and clinical leaders. These sites gave priority to staff training to support the programme and used the extra funds they were allocated in the ways indicated above.

Effects of change

The most common type of booking, adopted by 23 of the 24 pilot sites, was for day case admissions from hospital outpatient clinics and in some cases from general practice. The results reported below relate to day case admissions only. Three small pilot sites were not able to supply data in the requested format and are excluded from the analysis. Three other sites were not able to supply complete data on patients who did not attend and are excluded from that part of the analysis.

Patients waiting for admission with a booked or "to come in" date
The proportion of day case patients waiting for admission with a booked or "to come in" date increased from 51.1% to 72.7% between the end of March 1999 and the end of March 2000, and then fell to 66.2% by the end of March 2001 (table 1).

The pilot sites varied in performance both during and after the pilot phase (see fig 1 and table A on bmj.com). Three sites stand out for having achieved a high level of booking in 2001 (more than 80% of patients with a booked or "to come in" date) across more than half of all day case activity (sites 16, 4, and 12). Pilot sites that included most of the day cases within their scope (the proportion of all day cases in the participating trust or trusts) found it more difficult to increase booking activity beyond the level achieved in the first quarter of 2000 than sites with a more limited scope (fig 1).

View larger version (50K): [in this window] [in a new window]   Fig 1 Percentage of patients awaiting day case admission with booked admission date or "to come in" date at 20 pilot sites in first wave of the National Booked Admissions Programme, and scope of pilot sites (proportion of all day cases in the participating trust or trusts)

 

Patients failing to attend
The proportion of patients who did not attend fell from 5.7% to 3.1% between the first quarters of 1999 and 2000 and then increased to 4.0% in the first quarter of 2001 (table 1). The proportion of the pilot sites with a "Did not attend" rate of 3% increased from 35% (6/17) in the first quarter of 1999 to 53% (9/17) in both subsequent periods. The pilot sites varied considerably in the proportion of patients failing to attend (see fig 2 and table B on bmj.com).

View larger version (31K): [in this window] [in a new window]   Fig 2 Percentage of patients awaiting day case admission who failed to attend a booked appointment in 17 pilot sites in first wave of the National Booked Admissions Programme

 

Waiting times
The proportion of patients who had waited 6 months for elective surgery fell from 10.9% at the end of March 1999 to 10.5% at the end of March 2000 before rising to 11.9% at the end of March 2001 (table 1). Again the pilot sites showed wide variations (see fig 3 and table C on bmj.com).

View larger version (29K): [in this window] [in a new window]   Fig 3 Percentage of patients awaiting day case admission who waited 6 months for admission in 20 pilot sites in first wave of the National Booked Admissions Programme

 

Comparisons with non-pilot sites
We compared the pilot sites' experience with that of non-pilot sites for the seven commonest day case specialties included in the pilot sites. Data for non-pilot sites are drawn from all consultants in England who were not included in the first wave of the pilot programme (comprising consultants from the NHS trusts participating in the pilot sites in specialties outside the first wave, and consultants in NHS trusts not involved in the first wave). It was not possible to control for the characteristics of non-pilot sites, and so the comparison should be regarded as illustrative only.

Pilot sites had a higher proportion of patients with a booked or "to come in" date and a lower proportion of patients waiting 6 months at the end of each quarter compared with the non-pilot sites (table 2). In the pilot sites the proportion of patients not attending declined substantially in the pilot phase, but this was partly offset by a subsequent increase. In the non-pilot sites, the proportion of patients not attending fell each year. (The data in table 2 differ from those in table 1 because they are for seven specialties only.)

View this table: [in this window] [in a new window]   Table 2 Day case admissions among 23 pilot sites in the first wave of the National Booked Admissions Programme and among non-pilot sites for 1999, 2000, and 2001. Values are percentages (denominators) of patients unless stated otherwise

 

Figure 4 uses data at trust level to show the progress that needs to be made by both the pilot and non-pilot sites in achieving the national targets for booking admissions and waiting times. The aim is that all patients waiting for a day case admission should be able to book an appointment by March 2004, and that no patient should wait longer than six months by the end of 2005. Despite the progress made by the pilot sites, the NHS faces a substantial challenge in this area.

View larger version (38K): [in this window] [in a new window]   Fig 4 Percentage of patients awaiting day case admission with a booked or "to come in" date and percentage waiting 6 months for admission in the pilot sites in first wave of the National Booked Admissions Programme and in all other NHS trusts in England in relation to current targets (all data from KH07 central returns)

 

Lessons learnt

With the support of the National Patients' Access Team, the pilot sites were able to redesign services to improve access for patients. A small number of pilot sites achieved and sustained a high level of booking across more than half of all admissions for day case activity. Despite the progress made during the pilot phase, however, not all of the increase in the proportion of patients with a booked or "to come in" date was sustained. Analysis of activity data for the NHS over the three periods we studied indicates that pressures from emergency admissions and other sources cannot explain the difficulties that were encountered in sustaining the development of booking.⁸ However, some of the pilot sites lacked management continuity as a result of changes among project managers and because of the transfer of some of the functions previously performed by the National Patients' Access Team to NHS regional offices. These changes may have affected the sustainability of booking.

Results from surveys
We conducted a survey of project managers in the 20 pilot sites included in our analysis. Eighteen managers from 15 sites completed the questionnaire we sent about the factors that facilitated and inhibited booking, and we had telephone interviews with managers in two other sites. Three sites provided no information.

Responses indicated that the main factors facilitating booking were the booking processes becoming more familiar, embedded, and routine; capacity being increased through the use of the private sector, weekend working, and similar initiatives; and the more efficient use of existing facilities. The last of these included the use of preoperative assessment clinics to ensure that patients were fit for surgery. Also helpful had been the phasing in of booking systems, starting with enthusiastic consultants and rolling out to others, and the willingness of staff, especially consultants, to plan their leave (see box).

A wide range of issues was reported to have hindered booking (see box). These included lack of capacity, lengthening waiting lists, increasing referrals, problems recruiting staff, trust mergers, and patients wanting to change their appointments because of a perception that services were more accessible. Consultants' reluctance to change established ways of working and to give up their freedom to determine relative priority was also widely reported to have slowed the implementation of booking. In some cases, this included an unwillingness to plan leave sufficiently far ahead to enable booked dates to be agreed and honoured.

We undertook a survey among hospital consultants in three of the pilot sites to assess their attitudes to booking, and the main factors inhibiting its development. The response rate was 77% (103/133). Although most respondents were enthusiastic or supportive of booking, about a quarter were sceptical or not convinced of its value. The greatest challenges to booking were perceived to be capacity constraints (especially shortages of beds, theatre time, and staff) and long waiting times. These findings were confirmed by project managers, who noted the need to show that booking offered benefits to staff as well as patients in order to overcome the scepticism of consultants. The managers sought to persuade consultants to become involved in booking through showing that booking resulted in fewer cancellations and patients failing to attend and by the use of incentives like the purchase of additional equipment and computers.

Variations in pilot sites' performance
Given that all the pilot sites received similar levels of advice and support from the National Patients' Access Team and implemented booking as part of the same pilot programme, the large variations in performance between the pilot sites were probably due to local differences in the NHS trusts that participated. Interviews with those involved in the programme indicated that the best performing pilot sites were those with effective leadership by chief executives and senior clinicians, a dedicated project manager and team, and a flexible approach to the booking system to accommodate clinicians' preferences. In contrast, pilot sites that faced capacity constraints and waiting times over six months, that relied on complex information and communications technology, and had to deal with mergers of hospital trusts were at a disadvantage.

Key factors affecting performance of booking admissions for day case surgery during pilot phase reported by project managers Facilitators Booking had become more familiar, embedded, and routine Booking had been phased in, starting with the enthusiasts Capacity had been increased—such as through use of the private sector, weekend working, a mobile theatre, and arranging a semi-urgent operating list Operating theatres were used more efficiently, and preoperative assessments introduced to ensure patients were fit for surgery Staff leave was planned and managed Number of patients failing to attend was reduced Inhibitors Capacity was insufficient—funds for waiting list initiatives were no longer available to buy extra capacity, emergency admissions affected booking, waiting times were lengthening (in some cases this involved day case facilities being used for urgent inpatient work), and referrals were increasing Individual specialties experienced particular pressures and difficulties with high volumes of patients, lengthening waits for appointments, and multiple access routes Difficulties arose in recruiting and training staff such as consultants, nurses, theatre staff, and booking clerks Trust mergers had an adverse impact, such as resulting in services transferring between sites and unsettling established booking arrangements Patients wanted to change appointments or simply not attend because of the perception that services were more accessible, leading to an increase in cancellations and failures to attend Booking processes not understood by patients as an opportunity to mutually agree dates, or did not allow a "cooling off" period for patients Consultant resistance to adopting booking practices and to planning leave

Key learning points Services can be made more accessible and convenient to patients through initiatives like the National Booked Admissions Programme External support and additional funding enabled NHS trusts to redesign services and to bring about change Effective local leadership by trust chief executives, senior clinicians, and project managers is essential to support change Sustaining quality improvements like booking admissions and extending them beyond a small number of pilot sites that achieved high levels of booking is a major challenge

Next steps

The first wave of the National Booked Admissions Programme enabled hospitals that were already performing well in offering patients accessible services to make further progress in increasing levels of booking appointments. It also showed the difficulty for the NHS in sustaining innovations of this kind beyond the pilot phase, and in hitting the ambitious targets that have been set for booking and waiting time for the NHS as a whole. The evidence from this study is that progress is possible where there is effective local leadership and enough capacity to enable waiting times to be reduced.

In response to the scale of the challenge relating to both booking and waiting times (see fig 4) renewed effort and extra resources were put into the implementation of booked admissions by the National Patients' Access Team and subsequently the NHS Modernisation Agency. The National Booked Admissions Programme is now in its fourth wave, known as "Moving to mainstream," and encompasses all NHS trusts in England. The programme is drawing on the experience of the pilot sites we evaluated. Across the NHS, efforts to increase booking levels are focusing on increasing capacity, reducing waiting times, and strengthening leadership and management arrangements. The evidence of this study is that these efforts need to be pursued with vigour if the targets that have been set are to be achieved.

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Extra tables with data for individual pilot sites appear on bmj.com

We thank the staff in the 24 pilot sites who gave freely of their time in enabling us to gather data.

Contributors: HMcL participated in the design of the quantitative analysis, collected and analysed the quantitative data, and collected and analysed the data from the survey of project managers. HMcL, CH, and RK jointly wrote the paper. CH led the evaluation. CH, RK, and Philip Meredith collected and analysed the qualitative data. John Yates and James Raftery provided advice on the design of the quantitative analysis. HMcL and CH are guarantors for the study.

Funding: Department of Health. The views expressed in this paper are those of the authors and are not necessarily those of the funders.

Competing interests: CH is currently seconded to the Department of Health, where his work includes involvement in developing policy on waiting, booking, and choice.

References

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9. Department of Health. "GPs to book patients' hospital appointments on the spot." Press release, 98/297, 20 Jul 1998. www.newsreleasearchive.net/coi/depts/GDH/coi4099e.ok (accessed 10 Oct 2003).
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(Accepted July 29, 2003)

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