Elective Demand Management in Pennine Lancashire

Dr Malcolm Ridgway Vice Chair of Blackburn with Darwen CCG

A celebration of those ‘light bulb moments’ that are transforming patient experience and care across the North West

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Overview

A strategy and action plan has been developed to reduce elective demand management in Pennine Lancashire. The key elements are;•Peer review of referrals•Education•Shared decision making•Software decision support•Interventions of limited clinical priority•Alternative providers (GPwSIs, minor surgery)

Referral Management – Pennine Lancs approach• Evidence base reviewed (Ben Barr public health)• Small group formed from the 2 CCGs (Karen

Oddie, Kirsty Slinger, David White, Malcolm Ridgway - chair)

• Draft strategy produced• Refined following joint work with AQUA and the

SHA• Prioritised implementation plan then produced

There is considerable scope to improve the quality of referrals…..

The available national evidence on the current quality of referral suggests that:

• not all referrals are necessary in clinical terms, and a substantial proportion is discretionary and avoidable

• there are patients who need a referral but may fail to receive one • a large number of patients currently referred to secondary care

could be seen alternative settings • a considerable number of referral letters lack the necessary

information• there is frequently no shared understanding of the purpose of the

referral among the GP, the patient and the consultant• the appropriate investigations have not always taken place prior to

referral.

“ Referral management: lessons for success - The King’s Fund 2010”

Referral Management – Key Principles;

•Referral Demand Management dependant on improved Referral Quality•Evidence shows that Peer Review is key to improving Referral Quality;

– Review of referral data– Review of referral letters (internally or externally)

•Any system has to be slick, quick, evidence based, improve referral behaviour, cost effective, sustainable

Data Review

• The is significant variation in referral behaviour between GPs

• Even allowing for similar demographics and disease prevalence

• There is variation in the variation eg between specialities

• You do not know what you do not know

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1 2 3 4 5 PCT

Referrals Review

•Local – within the practice (QP6)•External – between practices (QP7)•External – Consultant or GPwSI triage

Education and timely feedback required to improve quality and change behaviour

Grouping potential interventions

Potential interventions grouped according to their possible impact and implementation rating (as per AQuA):

High /med impact and easier implementation

High/med impact but harder to implement

Med impact and easy /med implementation

Low impact / harder to implement

Grouping potential interventions

HIGHER

IMPL

EMEN

TATI

ON

Shared Decision Making

Financial Incentives

Undifferentiated restrictions on access

to low value careReferral Management

Centres

Clinical Assessment and Triage

Clinical Referral Guidelines

GP EducationValue Based CommissioningPatient Decision

Aids

Structured referral systems

Referral peer review and Feedback

LOWER IMPACT

EASIER

Specific Interventions and the Pennine Lancashire ApproachPeer Review and QoF Green•Utilisation of updated QoF targets for referral reviews and pathway implementation (elective component)•Year 1

– internal practice review and report– Large event for groups of practices to discuss, collated ideas

and information, developed the 3 pathways for implementation

•Year 2– Internal practice review – different specialities, report to CCG– Practice “groupings” formed to discuss referrals and joint

working, report to CCG– Pathways to be developed for implementation

Specific Interventions and the Pennine Lancashire ApproachPeer Review ctd•Consultants and others role – “joint accountability for demand management”•Ongoing practice referral review – locums, registrars, nurse practitioners, as part of CPD

Specific Interventions and the Pennine Lancashire ApproachStructured Referral Systems Green•Referral Proformas and Miniguides (electronic)

– Lot of work involved in agreeing guidelines and creating the electronic forms – multiple GP systems

– “2 minute window” – must be quick and slick– Problems with location, uploading to GP systems, updating etc

•Map of Medicines?•IT referral management systems

– RF Pathfinder, Arezzo, MoM, Isabel, McKesson– Issues of integration, time, clunkiness, appropriateness,

customisation workload, cost etc– Potentially the “Holy Grail” of the future

Specific Interventions and the Pennine Lancashire ApproachShared Decision Making and Decision Aids Green•Strong evidence base for effectiveness though harder to implement•Decision Aids (Amber) currently on NHSD site eg Hip and Knee OA, Cataract. Medium impact, easy to implement.•Informed patients make the decision – usually about interventions•Courses for train the trainer in November and into next year – protected time.

Specific Interventions and the Pennine Lancashire ApproachAdvice Services Green?•Already integral part of CaB – free!

– Intermittently used and supported– Many referrals not now sent via CaB

•Formalised Advice services– Tariff to be agreed (?£20-30)– Systematic reliable process– Structured advice form/guide – all required data present– Use of CaB to track and monitor– Useful in “complex” specialities eg renal, haematology,

cardiology

Specific Interventions and the Pennine Lancashire ApproachReferral Gateways Red•Low impact – deskill and annoy GPs, inconvenience patients, sustainability, cost•Reasonably easy to implement – CaB, bespoke software•Seen as a “Quick fix”

– Early gains - being watched!– Education key for quality improvement and

sustainability– Some use referral proformas

Specific Interventions and the Pennine Lancashire ApproachAdvice and Navigation LES Amber?•Panel of GPs and GPwSIs – CCG sessional rates•4 specialities - high demand areas and or alternative providers;

– General surgery– Rheumatology– Dermatology– Orthopaedics

•Small payment to practices for increased bureaucracy•Advisory only •Utilises CaB system – “free”, good reporting, panel can use at home

Specific Interventions and the Pennine Lancashire ApproachClinical Referral Guidelines Red•Little evidence of efficacy•Stored and lost – rarely used sustainably•Variable formats - paper, electronic•Often out of date – or using older versions•Some have referral forms – paper!, variable format•Map of Medicines, Mentor?

– Clunky– Not quick and slick – Useful for later reference, learning, PDP etc

Specific Interventions and the Pennine Lancashire ApproachInterventions of Limited Clinical Priority Amber?•Lancashire wide initiative•“Principles of Commissioning” devised and agreed•Wide involvement of public health, GPs, Consultants, Nurses, public•Evidence based (NICE, SIGN) or “cosmetic”

– Many already in force eg tattoo removal, reversal of sterilisation– Guidance available eg Tonsillectomy, Grommets, Hysterectomy– Complementary therapies – Not an absolute ban – some room for interpretation eg skin tags

can be removed if causing “discomfort”– Have to be agreed and implemented by all providers

Specific Interventions and the Pennine Lancashire ApproachEducation Green•Golden thread to improve quality and sustainability•Part of referral review process •Protected Learning Time

– BwD has 9 afternoon sessions per year– Strong clinical focus– Curriculum guided by CCG (demand management initiatives,

QoF, quality/variation, CPDs)

Specific Interventions and the Pennine Lancashire ApproachInterventions that are “out” RED!!•Financial incentives

– DH outlawed– Unethical– Reduce quality– CCGs and GPs open to probity complaints

•Rationing– Still sufficient “waste” in the system– How do you choose what to ration? Public vs Clinical view?– Issues with inequality and discrimination (smokers, overweight,

race, gender etc)

Summary• Referral Demand Management is about;

– Quality improvement– Peer Review– Education– Using the best evidence (clinical and methodology)– Quick and slick processes (2 minute window)– Integrated real time IT decision support probably the

future

Thank you – Questions?

Links;•m.ridgway@nhs.net•http://www.bwd.nhs.uk/policies-and-procedures/policies-of-limited-clinical-value/

Dr Malcolm Ridgway

Clinical Director for Quality and Effectiveness

Vice Chair Blackburn with Darwen CCG