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The 18-week programme: implications for nurses

By December 2008, no patient will have to wait longer than 18 weeks from GP referral to hospital treatment. Philippa Robinson from the Department of Health explains what the plan is all about and discusses the vital role of nurses in delivering and sustaining 18-week patient pathways

Philippa Robinson
RGN RM RHV BSc(Psychology)
18 Weeks National Implementation Director
Department of Health

Delivering a maximum patient pathway of 18 weeks for elective care must be one of the most exciting and important changes that the NHS has embarked upon, but it involves unparalleled amounts of reform. Doing the same thing more quickly will not help us to meet this target; what is needed is cultural change - change in the way we work, and the way we deliver services locally.

Why 18 weeks?
The 2004 NHS Improvement Plan set out the idea for reform: "By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment." Since then, the Department of Health's 18 Weeks team has been hard at work turning this goal into a reality, identifying how to support the NHS to deliver elective pathways with no delays, devising rules and guidance to help delivery, and supporting the roll-out of large scale changes across the service.
In initial consultations, patients told us that 18 weeks would be an acceptable wait for nonemergency consultant-led treatment. And we have kept the patients at the forefront of this programme - after all, they are the real reason we have embarked on such an ambitious task. Lengthy delays are simply unacceptable when we are talking about people's health and quality of life, and faster, more effective treatment will help people get on the road to recovery much quicker than has historically been the case.
Previously hidden waits, such as those for some diagnostic tests, are on the road to being eliminated. Building on the experience of the cancer waiting times target, 18 weeks referral to treatment data are measuring the entire patient pathway, from the moment the patient is referred into care until their treatment begins. In transforming the way that the NHS works, we are dramatically improving the patient experience.
Already we are seeing results. It is so heartening to see a reduction in waiting times for imaging, a previous bottleneck - the fact that we are now talking about a three week window for imaging tests would have been unimaginable a year ago. And this fantastic news is only the tip of the iceberg - we even have sites around the country already delivering on 18 weeks, proving that it is possible.
Now, the first milestone is looming large. By March, the NHS should be delivering 18-week pathways for 85% of patients who require admission to hospital, and for 90% of patients not needing admission - and by the end of this year, where it is clinically appropriate and the patient is fit and ready to begin, all patients will begin treatment within 18 weeks, with the average pathway much shorter.

Benefits for patients
It goes without saying that lengthy delays are not ideal for patients or the NHS, and so moving the 18-week pathways and bringing care closer to home is the right move.
Patients will receive faster access to treatment and care; the average pathway will be just eight or nine weeks. This means less time spent in hospital for tests and treatments, as more services are provided by GPs and in community settings. As services are reorganised and appropriate tests and treatments are synchronised, fewer hospital appointments will be made, allowing those resources to be better optimised.
A more holistic approach to care means prompt attention and more convenient appointments, which leads to less disruption to daily life and leaves patients with greater confidence in the health system. They will have a better understanding of what to expect from their treatment and care, and when to expect it.

Benefits for staff
Happier, more informed patients and improvement in processes and systems ultimately means a better flow of patients through the system, easing congestion and improving staff morale.
The aim of 18 weeks is to make it easier to plan and manage workload, resulting in more productive working time. There will be a better use of professional time, resulting in improved relationships, both between colleagues and with patients.
Faster provision of treatment and care should also result in less emergency activity caused by long waits, and the opportunity to carry out more day case surgery. The end result will be more satisfied patients, and greater job satisfaction in the NHS.

Practice-based commissioning
In order to speed up pathways, it is necessary to look at how you deliver services. In many instances, a move to practice-based commissioning (PBC) has helped use skills across the clinical team more effectively, ensuring people get the right level of care, in the right place, at the right time.
Primary and secondary care can together forge strong partnerships to deliver better care for patients. By redesigning services to divert those who do not need to go to hospital, patients can be treated more locally, and the capacity of specialists in secondary care to treat complex referrals more quickly is increased. Many services across the country are finding a move to "one-stop shops" - where a patient can undergo referral and diagnostic testing on the same day - are helping to deliver better treatment faster.

The role of staff
Waits of more than six months for a first outpatient appointment were not uncommon 10 years ago. That we are now talking about the entire pathway taking no more than 18 weeks is testament to the hard work and commitment of NHS staff.
At the heart of this are nurses. It might be easy to dismiss the nationally developed commissioning pathways - symptom-based guides for the NHS to take patients from referral to treatment in high volume specialties - as something that only GPs and consultants need to worry about, but nurses play a vital role in ensuring the pathway is as smooth as possible for patients, and to ensure that services developed locally, based on the pathways, are not medicocentric.
Many trusts and PCTs have looked at redesigning together; nurses have been involved and are now taking on new roles and learning new techniques. For example, Chesterfield Royal Hospital Foundation Trust (see Case study) moved towards a one-stop nurse-led prostate biopsy service in order to address 18 weeks, cancer waiting time targets and capacity issues. The move generated additional capacity, and freed consultant urologist colleagues to concentrate on areas of clinical work other than transrectal ultrasound and prostate biopsy.

Talk about it
But it's not all about extra tasks or role redesign. Something as simple as communication can make or break 18 weeks.
Nurses are at the proverbial frontline and have an important role to play in ensuring patients are well informed. Practice nurses need to make sure patients understand that they need to be available to start their entire pathway, and if there is a possibility that, say, a holiday will interfere, then they should delay their referral. Make it clear that they must show up for appointments, because if they don't then they may go right back to the beginning while wasting a slot that another patient could have used.
The patient experience is important, and will be the real measure of success for 18 weeks. The Department of Health is working on a patient experience survey that will ask questions about choice, cleanliness, timeliness, communication, and so on; your hard work will be rewarded with tangible proof of how your care is being experienced by patients.
While talking with patients is key, so is talking to your colleagues. The commissioning pathways have been designed to be tailored to local needs, and it is of utmost importance that nurses are involved in those local discussions. Whether you are in primary or secondary care, you should be meeting with GPs, consultants and allied health professionals to work together to deliver care closer to home. Get involved in the discussions now, or you and your patients may miss out on influencing the future.

We have the tools; you have the talent
Working together is one of the keys to achieving and sustaining 18 weeks - not only should all facets of the health service be linking up, but the Department of Health needs to work together with the NHS to ensure the policy is rooted in reality. We can provide the tools for delivery, but it's up to you to use those tools wisely and appropriately.
Talk to your local 18 weeks lead, or visit Know the rules and guidance (available on the website) intimately. Understand what is expected of you, and of your patients. Knowledge is power, and by combining that knowledge with your skills, achieving and sustaining 18 weeks becomes a lot easier.

While some may perceive NHS reform as being politically driven, the reality is that there is a real clinical need for change and 18 weeks is one important way in which this will be achieved. A maximum 18-week patient pathway will put the NHS at the forefront of international best practice, and will provide a better, more productive health service with tangible benefits for patients and for NHS staff.
Working together locally to better understand the obstacles that create unnecessary delays for patients, and maximising opportunities provided by NHS reforms, will drive the development of new ways of providing high-quality patient care.
At the centre of it all is you - the nursing community. Whether it's developing new skills, taking on new tasks or simply improving current communications, your role is vital in ensuring smooth pathways for patients.

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18 Weeks
Houses comprehensive guidance and resources, including materials on implementation and examples of good practice. Registering on the website gives you access to the forums, allowing discussion with peers about experiences and lessons learned, and will also see the monthly e-bulletin, 18 Weeks Watch, delivered to your inbox.The message of 18 weeks and the communications resources related to the programme can be found on the End Waiting, Change Lives campaign site at