Outpatient Redesign Programme

Outpatient Services Performance Improvement Programme

The VisionPerson-centred outpatient services delivering high quality care for all

The MissionTo ensure people can access a high quality, integrated, holistic outpatient services when they need it

Single Queue System

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20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

0-3Months

3-6Months

6-9Months

9-12Months

12-15Months

15-18Months

18-21Months

21-24Months

24-36Months

36-48Months

48+Months

Number

Patients awaiting outpatient consultation Jan 31st 2017 and 2018 in time bands

2018-01-31

2017-01-31

Otolaryngology (ENT)OrthopaedicsOphthalmologyUrologyDermatology

Core Principles• Patient-centred

• Standardised, clinically-designed, nationally-agreed pathways

• Electronic / paper-free

• Transparent – fit for purpose data systems

• New ways of working– Telemedicine/virtual healthcare– Advice only options– Multidisciplinary services– Direct access– Ambulatory care– Commissioning model– Activity based funding

Prioritising Patients & Referral Pathways

• Clinical prioritisation needs to be based on a set of agreed ‘definitions’ or ‘criteria’, with attached ‘clinically-recommended timeframes’.

• National working group comprised of range of surgical and medical specialty leads, clinical advisor, OSPIP, public health

Prioritisation Outcome

Clinical characteristics/outcomes of conditions within category

Recommended time to consultation to

minimise risk and/or achieve best clinical

outcomes Notes/discussion points

Immediate

• Imminent risk of death• Trauma major or minor• Irreversible deterioration if not seen

immediately

Same day

Patients should be sent to ED/minor injury unit /AMAU as appropriate, or a same day rapid access clinic where that facility exists

Urgent

• Risk of permanent damage to organ system if treatment is delayed beyond CRT

• Major functional impairment • Suspected malignant neoplastic

disease• Rapidly progressing dysfunction (over

a period of days or weeks) in established conditions

≤ 28 days

NCCP/Individual specialties and/or subspecialties may set urgent CRT at less than 28 days (e.g., as per breast disease)

Semi-Urgent

• Risk of damage to organ system if treatment is delayed beyond CRT

• Moderate functional impairment or progressive loss of function over a period of months or years

• Benign neoplastic disease• Significant restriction of economic

activity

≤ 13 weeks

Individual specialties and/or subspecialties and/or conditions may set semi-urgent CRT at less than 13 weeks for internal clinical management

Non-urgent

• Minimal risk of damage to organ system if treatment is delayed beyond 13 weeks

• Moderate functional impairment• Significant restriction of social activity• Management issues in established

conditions• Reassessment of stable/chronic

conditions that meet the criteria for review

≤ 26 weeks

Excluded

• Conditions that have no impact on physical well-being, e.g., work assessments, cosmetic surgery

• Sub-acute or minor conditions/complaints that will be safely diagnosed and/or managed in primary care.

Specialties can decide on specific conditions/complaints, based on literature and/or international best practice, taking account of Irish health system’s structure.

[1] Significant restriction resulting in inability to work/support self and/or dependants [2] Resulting in a deterioration of the person’s overall well-being and/or mental health

Progress to Date• Cardiology • Dermatology • Endocrinology • ENT• Gastroenterology• General Medicine• General Surgery• Gynaecology• Haematology• Immunology• Neurology• Ophthalmology• Orthopaedics• Paediatrics• Respiratory• Rheumatology• Urology

Urology

Symptoms/System

Clinical priority and recommended time-frame

Genitourinary traumaAll trauma Immediate (Same day)Urinary tract symptoms/presentationAcute ureteric colic Immediate (Same day)Septicaemia of suspected urinary origin Immediate (Same day)Acute and chronic urinary retention Immediate (Same day)Hydronephrosis Urgent (< 28 days)Visible, painless haematuria in adults or children Urgent (< 28 days)Microscopic haematuria in adults over 50 years Urgent (< 28 days)Microscopic haematuria in patients aged less than 50 Semi-Urgent (< 13 weeks)

Females aged 40 years and older who present with recurrent or persistent urinary tract

infection associated with haematuria Semi-Urgent (< 13 weeks)

Any UTI in a male Semi-Urgent (< 13 weeks)Females with recurrent, 3 or more per year, or persistent UTI Semi-Urgent (< 13 weeks)

Lower urinary tract symptoms classified severe as per International Prostate Symptom Score,

with or without renal impairment, yet no evidence of urinary retentionUrgent (< 28 days)

Lower urinary tract symptoms, classified as moderate as per International Prostate Symptom

Score, with no renal impairment

Non-Urgent (<26 weeks)

Lower urinary tract symptoms, classified as mild as per International Prostate Symptom Score,

with no renal impairmentManage in primary care

Female and male incontinence where conservative management fails Non-Urgent (<26 weeks)

Suspicious abdominal masses originating from the urinary tract found on examination and/or

imagingUrgent (< 28 days)

Abdominal pain suggestive of urinary tract origin but not typical acute ureteric colic Urgent (< 28 days)Renal calculi Semi-Urgent (< 13 weeks)Suspected neurogenic bladder Semi-Urgent (< 13 weeks)Scrotal SymptomsAcute scrotal pain Immediate (Same day)

Chronic scrotal pain (>3 months) Semi-Urgent (< 13 weeks)

Scrotal swellings suspicious for testicular cancer Urgent (< 28 days)Suspected hydrocele on clinical examination, or proven on ultrasound Non-Urgent (<26 weeks)Suspected epididymal cyst on clinical examination, or proven on ultrasound Non-Urgent (<26 weeks)Adolescent varicocoele Semi-Urgent (< 13 weeks)

An undescended testis (one that cannot be manipulated into the bottom of the scrotum) in

child >3 monthsSemi-Urgent (< 13 weeks)

ProstateElevated age-specific prostate specific antigen (PSA) in men under 70 in accordance with

current NCCP guidelines

Urgent (< 28 days)

Elevated age-specific prostate specific antigen (PSA) in men over 70 in accordance with current

NCCP guidelines

Urgent (< 28 days)

Hard, irregular prostate suspicious of prostate carcinoma (see NCCP guidelines) Semi-Urgent (< 13 weeks)See urinary tract symptoms for additional prostate-related conditions

Haematospermia Urgent (< 28 days)

PenisPriapism Immediate (Same day)

Suspected Peyronie’s disease Semi-Urgent (< 13 weeks)

Penile lesion suspicious for penile cancer Urgent (< 28 days)Chronic penile pain Semi-Urgent (< 13 weeks)

Erectile Dysfunction Non-Urgent (<26 weeks)

Non-retractile foreskin Non-Urgent (<26 weeks)

General Male fertility and Reproductive/sexual healthLoss of libido in males Non-Urgent (<26 weeks)

Male infertility Non-Urgent (<26 weeks)

Vasectomy / Reversal of vasectomy Non-Urgent (<26 weeks)

Pelvic SymptomsChronic pelvic pain Semi-Urgent (< 13 weeks)

Symptom-based

• ICPC-2Presenting complaint ICPC-2 code Grand Total % of totalProstate cancer assessment U26 461 14.8%

Urinary frequency/urgency U02 384 12.3%

Haematuria U06 345 11.1%

Cystitis/urinary infection other U71 325 10.4%

Scrotum/testis symptom/complaint other Y05 246 7.9%

Urinary calculus U95 188 6.0%

Penis symptom/complaint other Y04 166 5.3%

Urine symptom/complaint other U07 108 3.5%

Kidney symptom/complaint U14 102 3.3%

Pain in testis/scrotum Y02 97 3.1%

Urinary retention U08 88 2.8%

Balanitis Y75 79 2.5%

Incontinence urine U04 69 2.2%

Hydrocoele Y86 69 2.2%

Phimosis/redundant prepuce Y81 68 2.2%

Orchitis/epididymitis Y74 55 1.8%

Malignant neoplasm of kidney U75 45 1.4%

Dysuria/painful urination U01 41 1.3%

Sexual function symptom/complaint male Y08 36 1.2%

Pain in penis Y01 36 1.2%

Urethral discharge male Y03 25 0.8%

Malignant neoplasm urinary tract other U77 12 0.4%

Undescended testicle Y83 11 0.4%

Malignant neoplasm of bladder U76 9 0.3%

Infertility/subfertility male Y1Q 8 0.3%

Urinary symptom/complaint other U29 8 0.3%

Bladder symptom/complaint other U13 7 0.2%

Urination problems other U05 7 0.2%

Sterilization male Y13 6 0.2%

Injury urinary tract U80 3 0.1%

Benign neoplasm urinary tract U78 2 0.1%

Glomerulonephritis/nephrosis U88 2 0.1%

Malignant neoplasm male genital other Y78 2 0.1%

Prostate symptom/complaint Y06 1 0.0%

Fear of genital cancer male Y26 1 0.0%

Urinary disease other U99 1 0.0%

Benign/unspecified neoplasm male genital Y79 1 0.0%

Grand Total 3,114 100.0%

• ‘referral info’ set out per condition

• Consultant response items set out– Advice– Diagnostics– Virtual consultation– Request more information

Electronically Supported• GP decision support– Pathway enablement

• Central referral management

• Electronic triage or clinical prioritisation

• Consultant-GP engagement

• Consultant-patient engagement