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The EWTD and booking patients

17/08/2010
by Rob Findlay

The European Working Time Directive (EWTD) is a massive issue for hospital doctors, so anything that leads to better use of doctor time is a bonus. In this post we’ll take a look at improving the utilisation and predictability of doctor workload in clinic.

Clinics are not always planned and managed in the most scientific way, and instead a variety of local customs and practices apply around the hospital. Also local rules are often unclear when it comes to handling events like urgent referrals, peaks and troughs in demand, late cancellations, and all the other sources of disruption.

As well as increasing waiting times, this inconsistency can also waste doctor time. If urgent referrals are frequently squeezed into already-full clinics at the last minute, then clinics will overrun, putting pressure on doctors’ overall working hours. If on the other hand slack is being left in the system “just in case”, or troughs in demand are poorly managed, then doctors may be left unproductive during gaps between patients.

You might even suffer from both evils. An overrunning clinic always overruns at the end, but the unproductive gaps can be anytime.

In situations where the waiting list comes and goes, such as an A&E department, or a clinic with a very short waiting list, it is understandable that doctor time cannot be fully utilised. But where there is a persistent waiting list, which is more usual for outpatient and admitted patient waiting lists, the goal should be to book patients into all the slots available so that every doctor’s time is used productively.

It takes a certain amount of confidence, and some very clear rules about how bookings should be managed, to make this work in practice. When we were doing our research into patient scheduling, we made it an axiom that the available capacity should be fully utilised, for the simple reason that wasted capacity is the worst sin of all, leading to longer lists and longer waits as well as wasting money. So even if the motivation for introducing better booking rules may be to protect clinical priorities or reduce waiting times, all the other benefits of full capacity utilisation come built-in.

What does full capacity utilisation look like in practice? It is worth realising that full utilisation is not the same thing as a full appointments book. Custom and practice may over the years have whittled away at the capacity being declared available. For instance, it may have become normal to reduce the number of bookable slots in each clinic, in response to incidents or practices that happened years ago. Or perhaps patients are being passed to juniors only at the last minute without regard to their appointment times, with the inevitable result that some doctors have gaps in their schedules.

Using capacity fully means being realistic at the outset about the time available. How long does each first and follow-up appointment really need in clinic? How long does it really take to enter notes for each patient? When does the clinic really start and end? How many doctors will we actually have, and what kind of cases can each accept? And not least, how many follow-ups do we really need to make provision for?

In answering these questions you may feel the tug of past compromises; occasions when this or that was done for a reason that was expedient then but long-forgotten now. Those compromises need to be put to one side, because the benefits of full utilisation are so valuable for training, productivity, and performance.

Being honest about the capacity that is available is likely to have consequences: we may find that the waiting list is going to either grow unacceptably or disappear, or that activity will fall out of line with commissioners’ intentions. That is the trigger for further honest discussions about the amount of activity commissioners are going to pay for, and the relationship between the waiting list and waiting times. Those discussions may be frustrating, but it is better than wasting the precious, rationed time of highly-skilled and expensively-educated doctors.

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