Evaluating a new care model aimed at reducing waiting times for outpatients

The ROSMaC model is a one-stop clinic where a patient has access to the right clinicians and diagnostics. This piloted approach sought to improve user experience by making the patient journey more efficient with fewer steps and waits, ultimately providing a more comprehensive and timely experience for rheumatology patients. 

The ROSMaC pilot was led by Imperial College Healthcare NHS Trust (ICHT) in collaboration with the Healthshare Group (HG), supported and funded by NWL ICS. Its main objective was to reduce waiting times for MSK Rheumatology outpatients in NWL, specifically at ICHT. Imperial College Health Partners (ICHP) led the evaluation of this pilot, working closely with the ICHT and HG teams to determine the scope. The evaluation involved comparative analysis between the traditional model (Traditional Imperial Rheumatology Outpatient Clinic or TIROC), and the new ROSMaC model, and ultimately aimed to evaluate and evidence the impact of this new model of care. 

Success of the ROSMaC pilot could directly contribute to reduced waiting lists, reduced unwarranted variation in care, and prevent harm by ensuring that patients are seen in the right place, at the right time, with the right care. 

Rheumatology is a medical specialty that encompasses the diagnosis and treatment of conditions affecting joints, bones, muscles, and connective tissues. Musculoskeletal (MSK) health is at the core of rheumatology, as it involves addressing musculoskeletal disorders and diseases, such as arthritis, lupus, fibromyalgia, and vasculitis. 

MSK conditions are the leading cause of disability in the UK and poor MSK health has a significant impact on individuals, families, employers, the NHS, and the wider economy. It is estimated that over 30 million working days are lost due to MSK conditions each year in the UK, and they account for up to 30% of GP consultations in England (NHS England, 2019).  

In North West London (NWL), long wait times for rheumatology services are observed across trusts, mainly due to variations in service delivery linked to an imbalance between capacity and demand, as highlighted in the Get It Right First Time (GIRFT) for Rheumatology report (GIRFT, 2021) . Referral-to-treatment (RTT) timeframes for rheumatology outpatients exhibit significant variation, ranging from less than five weeks in the best-performing trusts, to over 30 weeks in others. Waiting times for rheumatology outpatients across NWL integrated care system (ICS) were further impacted by the COVID-19 pandemic. 

In the context of rheumatology, long wait times can have a direct impact on outcomes for patients. Early detection and evaluation of diseases such as early inflammatory arthritis, giant cell arteritis (GCA), and vasculitis can reduce the risk of long-term complications. 

In response to these challenges, an innovative model of care was developed to reduce the backlog of outpatient rheumatology patients: the Rheumatology One Stop Mass Clinic (ROSMaC).  

The evaluation involved comparative analysis between the Traditional Imperial Rheumatology Outpatient Clinic (TIROC) and the ROSMaC, and used a mixed-methods approach of qualitative and quantitative analysis. This allowed for a comprehensive assessment of the ROSMaC service, with quantitative analysis providing objective data on the outputs, outcomes, and incremental costs of the service. Qualitative analysis provided insights on the process, outcomes, and sustainability of the service from the perspectives of key stakeholders. Finally, a cost analysis provided a financial estimate of the incremental costs of the service. 

Qualitative analysis: 

Project leads conducted semi-structured interviews with key stakeholders, including clinicians, commissioners, and administrative staff from ICHT, HG and the ICS.  

The interviews focused on five key areas, agreed by the evaluation steering group:   

• Views on the model  
• Staff experience 
• Enablers for success 
• Barriers and challenges 
• Recommendations for improvement

Insights showed that clinicians generally held a positive perception of the ROSMaC initiative, highlighting its effectiveness in reducing waiting times and providing comprehensive and efficient care.  

Quantitative analysis:  

The quantitative analysis involved collecting data from a random sample of 100 patients from each of the ROSMaC and TIROC services, on the outputs, outcomes, and incremental costs.

The evaluation of the ROSMaC service revealed positive outcomes in reducing waiting times and improving patient experience. Evidenced impact includes:  

• Reduction in patient waiting times: The ROSMaC initiative was effective in reducing waiting times for rheumatology appointments in NWL. The average waiting time from referral to appointment decreased by approximately two months (10.83 months for TIROC patients to 8.63 months for ROSMaC patients), and time from first appointment to diagnosis was drastically reduced for ROSMaC patients who on average received their diagnosis within the same month (1.25 months for TIROC patients, zero months for ROSMaC patients).
• Improved diagnostic efficiency: In comparison to the traditional model, the ROSMaC model demonstrated higher diagnostic efficiency. On average, patients required one appointment in the ROSMaC, resulting in a definitive diagnosis for 81% of patients, compared to 75% of patients in the TIROC who required an average of three appointments to receive a diagnosis.
• Incremental cost difference: There was some suggestive evidence for the ROSMaC having lower incremental costs for service delivery when compared to the TIROC. 
• Equally distributed access to services across patient demographics: The implementation of the ROSMaC did not lead to an exacerbation of existing inequalities in access to services across age, sex, ethnicity and socio-economic status.
• Staff experience: There was consistent feedback that the service enabled staff to provide a better patient experience through better utilisation of consultant time and skills, and an increased likelihood of being able to complete the patient journey from assessment, treatment and discharge in one clinic. Staff also reported the service had a positive impact on learning opportunities through multidisciplinary working. 

Opportunities identified for enhancing this new model include: 

• Administration processes: Administration was frequently cited as an area for improvement which will enhance the service as well as the experience of clinicians, administrators and patients. 
• IT systems and care coordination: There is an opportunity for better coordination of care through more effective use of data and connection of IT systems. There were significant challenges regarding system integration, compatibility, and accessibility, with Cerner and SystemOne identified specifically. These challenges led to difficulties in data sharing, making referrals, and accessing necessary information. IT issues also hindered clinicians’ ability to perform certain tasks, such as viewing patient records, which affected the overall smooth functioning of the clinic. 
• Improved collection and coding of data for future evaluations: The evaluation highlighted that the ROSMaC service can improve the standardised collection and coding of their patient data. This will ensure a more streamlined evaluation process in the future and ensure quality outputs.
• Enablers: Several themes emerged as key enablers to the service, and will be instrumental if it is to be extended in the future. These include effective collaboration and trust, access to suitable estate and infrastructure, strong clinical and strategic leadership, and a structured training programme.

In conclusion, the Rheumatology One Stop Mass Clinic initiative (ROSMaC) has proven to be a successful pilot program in NWL. Some of the key strengths of the initiative included the multidisciplinary approach, the collaboration between healthcare professionals, its one-stop-shop model, and its efficiency in service delivery.  

The evaluation of the initiative revealed positive outcomes, including a reduction in waiting times for rheumatology appointments and improved diagnostic efficiency. Furthermore, the ROSMaC model showed improved capability of closing the patient treatment loop when compared to the traditional model, by reducing the number of appointments needed for diagnosis.

The ROSMaC pilot has been recognised at national level, via NHS England GIRFT team as a model to be considered for reducing waiting lists. It is also likely to inform the NWL ICB Strategy moving forward. 

Following the success of this pilot, ROSMaC has been positioned as a future model to support outpatient waiting lists across other sites in NWL. 

To support further improvements across the ROSMaC service, the evaluation proposed a series of recommendations:  

• Develop structured training pathways with named supervisors to ensure consistent and effective skill development for staff in the ROSMaC setting. 
• Improve administrative processes, scheduling, and IT systems to optimise resource allocation and ensure seamless data sharing. 
• Strengthen patient follow-up.
• Improve data collection and coding.
• Ensure all relevant clinicians have access to relevant patient information to support clinical decision-making and improved care coordination between secondary and community services.
• Continued measurement: both TIROC and ROSMaC services should routinely and proactively collect and analyse Patient Reported Outcome Metrics (PROMs) and Patient Reported Experience Measures (PREMs) for continuous improvement and future service evaluation.
• Consider future, more comprehensive and advanced evaluations of the service including inferential statistics to investigate inequalities in access of care across population groups.