The Ministry of Health has today published the first release of developmental data from Phase 1 of the new National Patient Flow national collection.
National Patient Flow is a significant development which, in its full form, will measure the patient journey through secondary care services.
It will provide information on the patients referred for specialist services, the outcome of referrals and the time it takes patients to access care.
Today’s first data publication shows referrals for First Specialist Assessment, received between 1 July 2015 and 30 September 2015, and whether these referrals were accepted, declined or transferred.
The Ministry clinical leader on prioritisation, Dr Chris McEwan, says some of this information has never been gathered before, and will build understanding around where there is unmet referred demand.
‘Patients of course care very much about what happens to their referrals to secondary care. So too do those hospitals, who have to make decisions within finite resources, and primary care, who are very important in ongoing care.’
‘It is important to note that this is developmental data which we expect to be revised as the quality of the collection improves. While it’s useful to provide information by DHB, this data should not be used to compare outcomes between DHBs.’
Dr McEwan thanked DHBs for their substantial work with the Ministry around the new collection.
The new NPF data on referrals for FSA shows:
- 87 per cent of the 158,214 referrals in the three months ending September 2015 were accepted by DHBs
- 5 per cent (7229) of total referrals were declined as they did not meet the local threshold for assessment.
You can also access the data on Referrals for First Specialist Assessment along with supporting explanatory information:
- National Patient Flow: Prioritisation outcome of referrals for first specialist assessment tables (developmental)
Question and Answers on National Patient Flow
- What is National Patient Flow?
- What is the aim of NPF?
- What are the stages of NPF?
- What’s the first data release concerning?
- What caveats are there around the data?
- What’s the referrals process for a First Specialist Assessment?
- What do the outcomes of the referrals mean?
- Does this data tell us how much “unmet demand” or “need” there is?
- Does a high decline rate for FSAs mean that DHB needs more capacity?
- Does this data tell us what happens to people whose FSA referrals are declined?
- What use is this data to DHBs?
- What use is this data to primary care?
- What use is this data to patients?
- How often will this data be published?
National Patient Flow (NPF) is a new National Collection being developed by the Ministry of Health.
The collection includes information from District Health Boards (DHBs) on each patient’s journey through secondary and tertiary services. Once fully implemented, it will include information from the point that a referral is received by a DHB, through assessment, diagnostics and treatment, until a person is discharged.
Developing the NPF collection is a multi-year programme of work, with three stages of development.
New Zealand’s health system has been focusing in recent years on making sure patients receive the most appropriate services, in a timely way, and in the right setting.
More funding and improved services mean that for example, more people are receiving elective surgery every year.
But while capacity is growing well ahead of population growth and demographic change, we have never had a measure that tells us that patients are getting appropriate access to services in a timely manner. That is why the Ministry of Health has been working with DHBs on the comprehensive NPF system.
The information NPF will gather, and continue to gather, will be invaluable in many ways for further improving access and timeliness of care for patients.
NPF will allow a better understanding of the patient demand for services, the sector’s capacity to meet that demand, and how access varies.
NPF will improve knowledge of the complexities of the patient journey, so the sector can better link the services they need, and improve resources if there are constraints.
Phase 1 has collected information on referrals made to DHBs requesting a first specialist assessment (FSA).
Phase 2 concerns referrals for inpatient elective surgery; some cancer treatments e.g. radiotherapy and some diagnostic procedures e.g. colonoscopy.
Phase 3 introduces elements of the full NPF collection, including diagnostic imaging, referral classifications and identifiers linking related referrals to demonstrate the complete patient journey.
Data released in April 2016 relates only to Phase 1 of the National Patient Flow Collection. The data is outcomes for referrals for First Specialist Assessment received between 1 July and 30 September, 2015.
The data presented in these tables is developmental. The Ministry advises that you should not compare numbers between DHBs as:
- some DHBs are experiencing delays in their ability to submit corrected data, so there are known gaps and inconsistencies
- DHBs are working towards improvements in data quality and completeness, and the methodologies and assumptions they use to derive these measures are being refined.
A person who has a condition they think may require treatment typically sees their primary care provider first. This is often, but not always, a GP. They will assess the person’s condition and discuss the best options, including whether to refer the patient to a specialist (eg, an orthopaedic surgeon at a public hospital).
This referral for a First Specialist Assessment (an appointment between the patient and the specialist, at which the specialist assesses the person’s condition and recommends the best option of care for them) is assessed by a prioritising clinician. The clinician then makes a decision whether the patient requires a specialist assessment by considering the person’s level of need and their ability of benefit in comparison to others.
The clinician can decide whether to accept, decline or transfer the referral, or defer the decision and request for more tests to be conducted. A person with an accepted referral should receive a First Specialist Assessment within four months.
The system captures a number of possible outcomes for a referral to FSA. These are:
- Accepted – the referral has been prioritised and the service is to be offered to the patient
- Below Threshold – the referral is appropriate and the patient would benefit from an assessment, but the referral is below the DHB’s capacity threshold
- Insufficient Information – the prioritising clinician has determined there is not sufficient information available to prioritise the referral
- Not eligible for publicly funded care – it has been determined at the point of prioritisation that the patient is not eligible for publicly funded care
- Service Not Required – the prioritising clinician determines that the patient is below the clinical threshold and does not require the FSA, or can be offered an equivalent or more suitable service in primary care, or is unlikely to benefit from assessment
- Pending Test Results – The clinician has requested tests and the prioritisation outcome decision for the FSA is dependant on the results
- Transferred to Another DHB – the service is not provided at the DHB and the clinician has determined that the referral should be transferred to another DHB for consideration
- Transferred to Another Specialty – the prioritising clinician has determined that the referral should be considered by another specialty.
NPF will capture information on ‘unmet referred demand’.
'Unmet referred demand' is where a person is referred for a service, the prioritising clinician determines that the patient would benefit from the service, but DHB is not able to accept the patient because they are below the DHB's access threshold.
Not all referrals for a service require a specialist assessment.
NPF will identify when a patient’s referral is declined because there is a better alternative for management of their condition. In this instance, the referred demand is not 'unmet' - they are being intentionally declined to follow a different care pathway.
The concept of 'unmet need' is much greater than 'unmet referred demand'. There are a number of instances where a person may not access the services they need. For example:
- they may not consult their General Practitioner or other primary care provider (such as a physiotherapist) when they feel unwell or are in pain.
- their General Practitioner of other primary care provider may not refer them for hospital-level specialist advice
- they may not attend their appointments
- they may benefit from treatment for one condition, but have other medical conditions that make the treatment inadvisable.
New Zealand will always have more patients than our publicly funded non-urgent medical and surgical services can cope with at any one time. This has always been the case, and public health systems internationally face a similar challenge.
Nationally, DHBs have been working on ways to address ongoing demand. This includes:
- Increasing access to elective services (including FSA and treatment) through improving the quality and efficiency of services, and increasing investment annually
- Providing elective care within expected timeframes
- Since 2011, DHBs have worked hard to actively reduce the length of time patients wait for FSA and elective treatment
- From 1 January 2015, the maximum waiting time for FSA or elective treatment is four months
- Improving equity of access – through consistent implementation of clinical prioritisation tools, and increasing access in line with population share
- Streamlining pathways and processes.
This approach means that more New Zealanders are accessing elective care, faster. Between 2008/09 and 2014/15 the number of FSAs provided each year has increased from 432,000 to 542,000 – an average increase of 18,000 additional people receiving an FSA each year. This increase is keeping ahead of population growth.
Elective surgery is increasing every year in New Zealand and it remains a priority for the health system. In 2014/15, DHBs delivered just over 167,000 surgical operations, an increase of more than 41 percent since 2007/08.
Despite the increase in access to FSA achieved by DHBs, and the increase in elective surgery, demand is unlikely to be met in all specialties. With finite resources, it is important that DHBs prioritise their resources across specialties so they can best support those patients with the greatest level of need, and potential to benefit from assessment and treatment.
In Budget 2015, additional funding of $44m was announced over three years to increase the level of general surgery and orthopaedics, including major joint replacements, and DHBs are working to deliver this.
An additional $6m was allocated to trial ways to improve ongoing care for people with long-term musculoskeletal conditions. This is the Mobility Action Programme, and during 2016 this Ministry-led work will see a number of innovative approaches underway, with further models also under consideration.
NPF does not gather this information. Later phases of NPF will provide information linking related referrals, so we will understand whether patients who are initially declined an assessment subsequently go on to receive one.
It is important to emphasise that specialist care may be only one of a range of options for elective patients. Many people will benefit from other health interventions, such as physiotherapy, weight loss management and exercise programmes prior to consideration for surgical intervention.
Some patients who are declined an assessment, do not necessarily miss out on specialist care. As their condition changes, re-referral should result in timely access to publicly-funded care.
Understanding more about patient flow through hospitals helps us make improvements. NPF, once in full effect, is expected to assist by clarifying:
- Demand for hospital services, where it is coming from and where it is directed.
- Whether access to assessment and/or treatment is based on a patient’s level of need and ability to benefit.
- Some reasons for patients delays in accessing services, specifically whether these are patient or system driven.
NPF will help identify gaps in care, and where possible new models of care could be developed.
NPF will highlight differences in patient flows in DHBs, leading to work that can be done locally and in conjunction with others to improve access, and equity of access.
NPF will help to better plan services that meet the needs of the national and local populations, including identifying where investment or attention may need to be prioritised.
Primary care is a key part of the public health system and it plays an important role in managing elective services.
Positive partnerships between primary and secondary sectors are crucial in improving communication, facilitating new ways of providing services, and making sure patients can get the treatment options that can support them, at the right place and time.
It is anticipated that over time, information about referrals from NPF will help GPs and other referrers in their decisions around referral, and subsequent care of patients.
NPF is part of providing transparency within the health system. At its full extent, it will give patients a better picture of what is happening or is likely to happen in their care, whichever pathway it follows.
Developmental data from the National Patient Flow collection will be published every three months. Revisions of earlier published data may occur at the same time. Additional information may be included as more data becomes available.