Service Recovery Documents: The What, When and How

Grid 1

This grid has been produced to aid the standardisation of language and definitions as they relate to the phases of the COVID-19 epidemic in the UK. The evidence base for such definitions is limited (3,4). A practical and pragmatic approach has been taken, using commonplace terms: these will be adjusted as standardised language usage is updated.

The aim is to give Units a standard frame of reference and to allow them to assess where their Unit sits within the timeframe of the epidemic. This allows them to apply Grid 2 principles to service planning and delivery.

Grid 2

The purpose of this service planning and delivery grid is to avoid, where possible, unintentional harm to patients with non-COVID-19 related disease, as a result of disruption to service provision due to the COVID-19 environment. The content is consensus opinion based and is offered as guidance.

Each workbook holds a list of the most frequent clinical presentations, diagnoses, conditions and endoscopic procedures for each sub-specialty of GI medicine. The grid lists have been categorised in this manner, to align with ongoing requests from Government for data on these particular conditions. They have been prioritised on a clinical basis, fitting with our understanding of, emergency (<24 hours); urgent (1-2weeks); soon (within 4 weeks) and routine (>30 days) priority (see column A of each workbook).

The rest of the columns indicate the priority for service action, based on a ‘Continue’ (green) ‘Suspend’ (yellow) and ‘Start’ (orange) instruction.

There is general acceptance that the infection rates with COVID-19 may fluctuate as public health measures relax, so moving backwards to the level of activity in the preceding phase of the epidemic may be necessary for some Units. This will have to be judged at a local level.

Grid 3

NHS England intend to perform a gap analysis on data from all Trusts in England to estimate the delay to OP service times for patients referred to specialty care; comparing last year to this. By identifying the commonly used codes for the clinical descriptors we have generated, the aim is to support a unified approach using specific ICD-10 or OPCS coding.

Whilst the NHSE request is specific to England, it is likely that similar exercises to track and analyse service delivery for non-COVID-19 disease during the epidemic will be undertaken by all of the devolved administrations. Consistent use of codes by units throughout the UK will therefore be of paramount important if an equitable assessment of national services is to be made.

Although SNoMed coding is not widely used in most current hospital systems, looking to the future, we have been grateful to a national expert in this area to translate the clinical descriptors to SNoMed, so that future tracking might be made more consistent and further unified. Currently, procedures i.e. diagnostics, are not translatable to SNoMed, so only ICD-10 or OPCS codes are supplied for these.

Grid 3 is, therefore, a dictionary of codes to help standardise tracking and follow up.

In appendices 1-5, mitigations and service actions to manage each clinical condition or procedures, are suggested. These are not intended to be comprehensive.

They do however emphasise the importance of instituting and continuing appropriate specialist triage and the tracking of deferred procedures/appointments, to mitigate any potential harm to patients. Ring fenced human resource, both clinical and administrative, needs to be allocated to this activity. The BSG has already emphasised this point to NHS CEOs and the CMOs of the devolved administrations, early in the COVID-19 crisis (5). It is worth pointing out that if emergency clinical service (triage and advice) is continuing on a 24/7 basis, then equivalent administrative support needs to be considered.

In the current, unprecedented times, opportunity presents itself to transform health service delivery and productivity by utilising virtual triage and consultation methods delivered early in care pathways by senior decision makers. This will enable rapid and safe closure of episodes of care, increasing the productivity as well as safety and quality of healthcare provision (6, 7).

This transformation is more likely to be achieved if the following principles relating to service mitigations and service actions are implemented: –

• Use of senior specialist decision makers to perform early triage and discharge, dealing with all non-essential referrals up front by Advice and Guidance bringing to early closure clinical episodes. As a safety net in a small number of cases, deferred referralby GPs in the recovery phase of the epidemic would be possible if necessary, after further primary care review.
• The ‘essential ‘secondary care work is then carried out preferably virtually via tele-medicine or phone consultation by senior doctors capable of closing the episode with some degree of clinical certainty. These priority referrals continue during the plateau and deacceleration phases of COVID-19.
• Investigations/procedures which may need to be truly ‘deferred’ on grounds of safety and preventing contagion, should be re-prioritised by senior staff, before the procedures/tests are booked in order to maintain or accelerate clinical priority. Outcomes will then be driven by senior clinician priority setting which is ‘sense checked’ throughout the phases of the epidemic.

This will be an unfamiliar role for many and will seem counter to current management processes, which run on centrally automated booking priorities aligned to targets.

Three key things necessary to maintain a system of clinical priority allocation are: –

• the preservation of a team of senior decision makers capable of triaging and running such a service
• the rapid processing and tracking of these senior triage decisions (see Appendix 5) using, if necessary, administration staff rostered on a 6-day service basis. This would both cut down social contact in offices, adhering to social distancing guidance and remove the ‘bulge’ in administrative burden which occurs when booking and tracking processes get out of step with clinical activity
• the retention of specialist nurses in specialist roles to help support the above (5)

• Plan service delivery within a recognised, well defined framework using these Grids as guidance
• Secure ring fenced senior clinical and administrative support for non-COVID-19 related, high priority work
• Triage, Track and Review non-COVID-19 activity
• Consider an alternative staffing rota for administrative staff, to better support clinical triage work

1. Pandemic Influenza Preparedness and Response: A WHO Guidance Document. Geneva: World Health Organization; 2009. 4, THE WHO PANDEMIC PHASES. Available from: https://www.ncbi.nlm.nih.gov/books/NBK143061/
2. GI Endoscopy Activity and COVID-19: Next steps   https://www.bsg.org.uk/covid-19-advice/gi-endoscopy-activity-and-covid-19-next-steps/
3. Implementation of the APEC Action Plan on Prevention and Response to Avian and Influenza Pandemics: Progress Review and Building Capacity for Future Work 2007 https://apec.org/Publications/2007/06/Implementation-of-the-APEC-Action-Plan-on-Prevention-and-Response-to-Avian-and-Influenza-Pandemics-P

4. Evolution of a pandemic A(H1N1) 2009, April 2009 – August 2010, 2nd edition https://www.who.int/influenza/resources/publications/evolution_pandemic_Ah1n1/en/
5. Workforce planning letter from GIRFT Lead for GI and Hepatology and the BSG President https://www.bsg.org.uk/covid-19-advice/workforce-planning-letter-from-girft-lead-for-gi-and-hepatology-and-the-bsg-president/
6. Specialty guides for patient management during the coronavirus pandemic publications approval reference: 001559 https://www.england.nhs.uk/coronavirus/secondary-care/other-resources/specialty-guides/
7. Greenhalgh T, Wherton J, Shaw S. Interim summary of key literature and our evaluation of Attend Anywhere in Scotland. 2020; Available at: https://tec.scot/wp-content/uploads/2020/03/Greenhalgh-2020-Interim-summary-of-key-literature-and-our-empirical-work-on-video-consultations-1.docx

The BSG Executive is grateful to Professor Jonathan Brown for his expertise and advice on SNoMed coding for GI and hepatology conditions and to Jeanette Lea and Alan Yuen, Gloucestershire Hospitals NHS Foundation Trust, for their checking of the ICD-10 and OPCS procedure codes.