Thinking outside the box: ‘Almost half of these people shouldn’t have been on a waiting list in the first place’

The cardiology outpatient waiting list has been horrendous for a long time, even before the pandemic. It was unmanageable – we were always facing an uphill struggle. Every single year we’d end up running extra or 'initiative clinics' to reduce waiting times. Staffing shortages, overwhelming numbers of patient referrals, a lack of joined up thinking, poor communication with primary care; these issues were combined with the fact that triage for outpatient referrals was never really a top priority. Something else always took precedence.

We’ve always had major staffing pressures, but during the pandemic it became even worse. The single-handed cardiologist at Withybush was redeployed into general medicine. There was sickness absence, retirements, we lost office space. Patients were presenting much later with chronic diseases. The old paper referral system could take months, with letters going back and forth between secondary and primary care, at the risk of being lost or delayed. We noticed a lot of referrals that could have been treated by general medicine or could have been managed in primary care. Others were duplicate referrals which took up a slot that could have been used by someone else. This was a chance to streamline the whole of the cardiac outpatient service across the health board.

In September 2021, I was seconded to work on a project to tackle the backlog after being told to shield for medical reasons. I wanted to look at what worked well across consultant-, CNS- and ANP-led services and avoid duplication as much as possible. It was pointless for patients to attend three similar clinics with the same resulting outcome. We wanted to formalise and expand the MDT, maybe giving the nurses more time to discuss cases with the consultants, and to educate juniors and GPs about what a good referral looked like. Could that patient be treated in primary care more quickly and efficiently? Do they actually need a specialist referral which means sitting on a waiting list for up to two years?

I also looked at referral destination. Which was the best service or clinic to send patients? The default was general cardiology, but many patients could have been seen much more quickly by a specialist nurse clinic in a matter of weeks. I was conscious that referral letters could often be woefully inadequate, and the triage process was not always up to scratch, with key investigations sometimes missing from the patient history. Pre-pandemic, there are some patients who would have waited a year for cardiac surgery if they were lucky. With the new systems and more efficient collaboration, we’re able to turn them around in seven weeks.

We received almost 3,000 referrals to outpatient cardiology in 2021, just for Prince Philip Hospital. Every week, I would receive 90 patient records, all caught up in the pandemic backlog, to work through every week, often 12–14 hours a day and for each of those patients: I’d look at spreadsheets, clinical IT systems, check blood results, X-rays, ECGs, echocardiograms, coronary angiograms, Welsh Clinical Portal, their primary care record – the lot. We introduced a traffic light system and I’d contact the patient and their GP to apologise about the pandemic backlog and resulting delay in their care and let them know what was happening next.

I was also carrying out three, and later four remote general cardiology new patient clinics online every week. I would lead a full cardiology MDT with multiple subspecialties with access to five or six cardiac specialist nurses and ANPs from across the health board. In return the staff knew they could contact me by phone or email at any time, and I knew my patients were safe. I had access to CT coronary angiography and cardiac MRI outsource priority lists at a private hospital in Newport so we could fast-track some patients and obtain a swift and definitive diagnosis.

Of course, I was relying heavily on electronic outpatient triage and on having a good relationship with the cardiology service delivery team in Carmarthenshire and the clinical teams across all hospital sites in the health board. Obviously, I was still not on site or in my own ward.  But within a few months, the hard work paid off. Cardiology waiting lists reduced so much that the forecast for clearing the backlog was well ahead of schedule and the average waiting time to see a consultant was half what it used to be. Urgent cases were being assessed immediately.

It’s only one study of course, but I found that over nine months, assessing over 3,000 cardiac patients caught up in the pandemic backlog, many lessons were learned. In total, 47% of patients on the cardiology backlog new patient waiting list had been referred back to primary care with advice. Almost half of these people shouldn’t have been on a waiting list in the first place. It’s so inefficient. Only 9% were booked into an outpatient appointment, the majority of which were virtual. A total of 18% were booked for further cardiac tests, 12% were referred into community cardiac services with MDT support, and 16% were kept under echo surveillance in our valve clinics.

It was a huge team effort, and hard work, but so well worth it. A lot has changed. We now have a new electronic referral triage system which has overhauled the outpatient referral system and resulted in seamless communication between primary and secondary care. I have been educating GPs and their trainees about a minimum basic dataset of clinical information required for each common cardiac condition that would ensure the right patient is seen at the right time and in the best clinic. Communication with GPs and the quality of referrals have improved. Virtual clinics seem to be the norm now. I've realised that redirection to the community is extremely valuable. Many referrals can be managed within primary care without even needing to come to cardiology. Some lessons from the pandemic have been totally invaluable.

Dr Lena Izzat
Consultant in cardiology and general internal medicine
Hywel Dda University Health Board