ABSTRACT
OBJECTIVES: England's National Health Service (NHS) introduced a 62-day target, from referral to treatment, to make lung cancer patient pathways more efficient. This study aims to understand pathway delays that lead to breaches of the target when patients need care in both secondary and tertiary setting, so more than one institution is involved. DESIGN: Mixed methods cross case analysis. SETTING: Two tertiary referral hospitals in London. PARTICIPANTS: Database records of 53 patients were analysed. Nineteen sets of patient notes were used for pathway mapping. Seventeen doctors, four nurses, eight managers and administrators were interviewed. MAIN OUTCOME MEASURES: Qualitative methods include pathway mapping and semi-structured interviews. Quantitative analysis of patient pathway times from cancer services records. RESULTS: The majority of the patient pathway (68.4%) is spent in secondary centres. There is more variability in the processes of secondary centres but tertiary centres do not have perfect processes either. Three themes emerged from discussions: information flows, pathway performance and the role of the multidisciplinary approach. CONCLUSIONS: The actions of secondary centres have a greater influence on whether a patient breaches the 62-day target, compared with tertiary centres. Nevertheless variability exists in both, with potential for improvement.
ABSTRACT
OBJECTIVE: To describe silent time in the clinical consultation: who initiates and terminates it and at what stage most silence occurs. METHODS: We conducted an analysis of 127 multichannel video recordings of consultations by 12 GPs; filmed using the ALFA (Aggregation of Log Files for Analysis) open-source toolkit. The start and end of silence was manually coded using an observational data capture tool. We report who initiates and terminates silence, describe the proportion of the consultation, what happens within it and the distribution of silent periods by quartile of the consultation. RESULTS: We found the median proportion of silence was 12.3% and interquartile range 14.3%. Silent periods (52.4%) were both initiated and terminated by the doctor. The majority of silent time (78.1%) is spent on computer-based activities and physical examination. Silent periods which do not involve physical examination mainly occur in the second half of the consultation and represent 70.6% of the total duration and 64.8% of the episodes of silence. CONCLUSIONS: The computer is a third party in the GP consultation and often requires silent time during doctor-computer interaction. Doctors' control and patients allow silence for the doctor to complete tasks often involving the computer and also for time out from the consultation. There is a clear pattern of when doctors need most to have silence and consultation models should be developed that reflect this need.
