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    • Cantilever House Eltham Road Lee London SE12 8RN Switchboard 020 7206 3200 Direct line 020 7206 3371 Fax 020 7206 3251 Email: Greg.Russell@lewishampct.nhs.uk Effective Referral Management Programme for 2006/7 – 2007/8 1. Introduction and Context Lewisham PCT is strongly committed through its Commissioning Strategy to improving standards of all care, to providing more appropriate care for patients nearer to home wherever possible and to support people more actively to manage their health towards a longer and healthier life. These are the longer term NHS aims of high quality (as set out in the latest White Paper, Our Health etc). It must pursue these aims within the constraint of spending no more than its financial allocation and getting best value from it. This demand management programme is an ambitious attempt to systematically and corporately consolidate existing and new areas of activity that are known to, or are likely to add most value to health improvement and cost effectiveness and to remove inefficiencies. Clinicians’ practice and decision- making with and on behalf of patients are at the heart of the programme. There is no time to lose to stop spending money we cannot afford. The risks of inadequate delivery are great and set out in section 6 The demand management programme is our prime strategy for maximising quality and eliminating risk of deficit, supported by other measures that will also be rigorously performance managed in parallel. These include: • Programme for efficiencies and effectiveness in use of medicines • Monitoring the effectiveness of service level agreements • Efficiencies in provider services (staffing, buildings and other facilities) • Sharing or outsourcing services • Benefits realisation from Connecting for Health This paper will seek approval at the PCT Board on the 22nd June 2006. The paper has been developed following discussion at the LMC, PCT PEC, PBC Steering Group and UHL. The paper and the Directed Enhanced Service (See Appendix 1) has been developed and agreed with the four PBC clusters. The agreement of the Directed Enhanced Service with the PBC clusters which will involve all Lewisham practices. This agreement is the essential element of clinical engagement that will significantly increase the level of delivery within the programme. 2. Process Changes in activity and flows of money towards best practice will be demonstrated in the following domain areas:- 1 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • • Primary and Secondary Prevention Smoking, Influenza, Alcohol, GP Quality and Outcomes Framework areas. • Scheduled Care New Outpatient Referrals, Consultant-to-Consultant referrals, Follow-up Outpatients, Excluded Procedures, Reduction in Elective HRGs. • Unscheduled Care A&E Attends, Reduction in Unscheduled HRG’s and Admissions, Critical Care - Occupied Bed Days In each domain there will be the following key high level information:- • Baseline activity / Cost • Redesign processes • Reduction in activity / Cost 3. Primary and Secondary Prevention We have evidence concerning other schemes that are effective at reducing hospital admission and where PCT performance can be improved: 3.1 Stopping smoking programme The PCT and Local Authority will: • Achieve the target of 1574 smoking quitters in 2006/7 • Deliver the LPSA funded initiatives: a community development initiative targeted around out high smoking localities, introduce a workplace smoking quitters programme and begin social marketing across Lewisham. 3.2 Influenza vaccination programme • The PCT achieved 65% uptake for vaccination in 2005/6 and will reach the national target of 70% in 2006/7. 3.3 Alcohol strategy and its implementation The PCT and Local Authority will: • Complete the Alcohol Strategy in 2006/7 and appoint an Alcohol Co-ordinator to help implement the strategy. • Complete the pilot scheme for the Locally Enhanced Service (LES) in 31 practices in 2006/7 • Aim to achieve alcohol screening of 80% of new registrations to these practices and 70% in the defined target conditions. 2 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • • Complete the analysis of prevalence data on patients attending University Hospital Lewisham and develop ideas for an effective intervention in 2006/7. 3.4 Primary Care Quality and Outcomes Framework General Practice makes a major contribution to secondary prevention as part of the Quality and Outcomes Framework. We will seek to maximise the bandings secured by practices in 2006/7. The areas targeted include coronary heart disease, COPD, diabetes, depression, hypertension control, stroke, cancer and epilepsy. 3.5 Choosing Health The interagency delivery plan for Choosing Health: Making healthy choices easier will provide a comprehensive framework for prevention. This will focus around the key themes of health inequality reduction, smoking cessation and tobacco control, healthy eating, exercise promotion, obesity control, alcohol and sexual health. Initial work includes: • Launch by the Mayor of Lewisham of the Lewisham Food Strategy and the Sport, Leisure and Physical Activity strategy in July 2006. • Further development of the health trainers scheme and integrating this will the demand management programme. 4. Scheduled Care 4.1. Outpatient Referrals New Outpatient Referrals Baseline activity 2005/6 58,480 attendances / (unit cost £156) Total cost 9,122M Target reduction of 1% = 584 attendances / Cost reduction of £91K • PBC clusters provided with practice referral rates and Directed Enhanced Service payment is linked to establishing systems within each cluster, to address outlying practices in levels of referral. Consultant-to-Consultant Referrals • Removal of Consultant-to-Consultant referrals (other than urgent in cardiac/cancer and in other areas agreed with primary care for direct referrals e.g. TB. and HIV) with return to GPs. PBC clusters and UHL clinicians to agree process to ensure only necessary referrals to secondary care specialities are made through primary care. 4.2 Outpatient Follow – ups Baseline activity 2005/6 120,613 attendances / (unit cost £79) Cost £9.528M) Target reduction 2,774 attendances (25% growth level in 2005/6) / Cost reduction of £219K The PCT experienced the following differences in the outpatient plan compared with the outturn in 2005/6. 3 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Follow-up outpatients were identified as one of the Modernisation ’10 High Impact’ changes over two years ago. There was an expectation that the level of follow-up appointments would reduce as evidence showed that many were unnecessary or could be managed more efficiently in primary care. Outpatients 2005/6 Outturn Position @ 2005/6 prices First Follow Up Based Trust 2005/6 Plan Outturn 2005/6 Plan Outturn on M11 UHL Activity Activity Activity Activity 37,446 37,433 71,638 77,360 Value Value Value Value £4,606,232 £4,587,534 £6,312,803 £6,832,710 M10 King’s Activity Activity Activity Activity 11,724 11,512 16,864 20,237 Value Value Value Value £1,526,980 £1,535,101 £1,196,670 £1,436,004 M9 Guy’s Activity Activity Activity Activity 8,837 9,535 21,017 23,016 Value Value Value Value £1,704,708 £1,804,216 £2,186,521 £2,363,621 T Activity Activity Activity Activity o 58,007 58,480 109,519 120,613 t Value Value Value Value a £7,837,920 £7,926,851 £9,695,994 £10,632,335 l s The key issues are identified as follows: • The growth in new outpatient referrals has largely stabilised with an insignificant growth in 2005/6. • The growth in outpatient follow-ups has cost the PCT £973K in 2005/6. • Payment by results methodology means all follow-ups are paid for with limited ability from PbC/PCT commissioners to control the activity. • In 2006/7 Lewisham Hospital will include nurse led follow-ups as part of PBR and this will add a further 12% of activity previously not paid for under local prices. 4 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • In the absence of a SE sector or London position where Trusts are only paid for follow-ups at a benchmarked level for each speciality the PCT will adopt the following approaches:- • In the Directed Enhanced Service all practices will review patients with 2 or more follow-up appointments • PbC redesigns in the specific areas of Musculo-skeletal, Diabetes, Gynaecology, Dermatology will address follow up appointments 4.3 Elective Procedures 4.3.1. Excluded Procedures to be implemented in 2006/7 SLA Activity and costs estimate £100K All PCTs in SE London apply contract exclusions broadly in line with SE London guidance, and comparable to those applied by Lewisham PCT. Lewisham PCT’s current policy focuses on the following areas: • Complementary therapies • Cosmetic surgery • Excision of benign skin lesions • Laser therapy for benign skin lesions • Non-medical circumcision • Reversal of male and female sterilisation • Removal of varicose veins • Diagnostic dilatation and curettage for women under 40 • Assisted Conceptions The PCT’s Exceptional Treatment Arrangements Panel (ETA Panel) receives regular requests for patient approvals for homeopathy and other complementary medicine, assisted conception, cosmetic surgery and laser therapy, indicating some adherence to these aspects of the exclusions by trusts. The audit currently being undertake will ensure complete implementation of these policies Lewisham PCT will work together with other PCTs in London to identify additional contract exclusions. The potential for savings are currently being examined by the London Health Observatory. 4.3.2. Analysis of high-level HRGs Reduction in Elective HRGs Baseline activity 2005/6 4523 procedures / Cost £5.463M (unit cost £1203) Target reduction 5% = 226 procedures / Cost reduction of £271K There is potential scope for savings in area with anomalously high acute activity. An Analysis of all HRGs having >50 episodes in the year 2004/5, standardised to the National HES data for 2003/4, where Standardise Episode Ratios (SERs) for Lewisham were higher than the national rate. The following areas where identified as 5 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • having anomalously high activity, where alternative pathway management may produce savings on hospital care. For these specialities, the following table shows a summary of the potential savings (episodes relating to specific HRGs only) Specialty Lewisham Expected Excess Potential episodes episodes episodes APC saving (£) Oral Surgery 291 122 169 112736 Dermatology / 836 122 714 996083 Plastic surgery Urology 891 631 260 369975 Gynaecology 2505 1796 709 760249 Total 4523 2671 1852 2239043 If Lewisham’s hospitalisation rates in the specified HRGs where the current rates seem anomalously high were reduced to the national averages then savings in the region of £2,000,000 could be made. There are other areas of high hospitalisation where action will be taken to examine alternative management plans: • Kidney conditions and urinary tract infections. These accounted for 625 admissions and were between 30 and 50 % higher than nationally. • Hypertension was also high and although accounting for only 100 admissions, these were 400% higher than expected. These admissions may well reflect high outpatient usage as well. • The use of hospital for maternity care was also high. Caesarian Section rates were 90% higher than average from the HRG analysis, although other sources from midwife returns suggest this is more like 40%. This alone may represent a cost burden of up to £500,000 compared with routine delivery. The use of hospital antenatally was also 58% higher than nationally. 4.4 Clinical Redesign Processes The PCT has initiated areas of redesign, which are delivering benefits. Some of these will be continued as part of the business planning process for Practice Based Commissioning (see below). Others will continue and be improved in 2006/7: • Community Phlebotomy • Community Anticoagulation • Community Chronic Obstructive Pulmonary Disease and pulmonary rehabilitation management • Community Sickle Cell Disease management Practice Based Commissioning has selected to following areas for business case development in 2006/7. These will focus on reducing first referrals and provide 6 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • community alternatives to secondary care follow-ups in the following areas linked to the HRG analysis: • Musculo-skeletal • Diabetes • Gynaecology • Dermatology • Paediatric dermatology 5. Unscheduled Care 5.1. Accident and Emergency Attends Baseline activity 2005/6 113,505 attendances (unit price £54 minors) Target reduction 2% = 2270 attendances / Cost reduction £25K (deducted at 20% marginal) • Front end A&E redesign – Second phase of pilot with primary care triage, minor cases seen by nurses and GPs accessing patients with potential for admission. Second phase of pilot will run from June to September 2006, with finalised service model implemented from December 2006. Key performance indicators being collected and analysed during the pilot are number of attendances, use of diagnostic tests, referral to outpatients and unscheduled admissions. 5.2. Unscheduled admissions Baseline activity admissions outturn in 2005/6, 11656 patients (excluding paediatric and maternity) Target Reduction in activity 2006/7 6% (Total 696 patients below 2005/6 outturn) & 2007/8 further 6% (1392 patients below 2005/6 outturn) £1,589K saving only releases £795K due to deduction at 50% marginal • Reductions in unscheduled admissions is one of the PBC clusters six priority redesign areas. • London Ambulance Service – Emergency Care Practitioners • Linked to A&E redesign, restructuring and investment in intermediate care in 2006/7 – 7/8. £1.94M in beds and Community Rapid Response Team. Planned reduction of unscheduled admissions in 2006/7 of 6% (699 spells) at University Hospital Lewisham. Further 6% planned for 2007/8 • Linked to Intermediate Care and developing chronic disease management of patients in the community, expansion of Community Matrons from 4 to 10 in 2006/7 within existing community nursing resources. • Redesign of community nursing service in 2006/7 to expand case management role of senior nurses and ensure an unscheduled care pathway that facilitates maintaining people in the community. 5.3. Critical Care 7 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Baseline activity 1749 Occupied Bed Days / Cost & Target Reduction in activity 5% = 87 OBDs / Cost reduction £213K New arrangements for commissioning intensive care are to be implemented from 1st June 2006. During 2005/6, Lewisham PCT experienced growth in costs associated with intensive care. An analysis of the three years 2003/4 to 2005/6 revealed that 2004/5 was a low year for intensive care use. By setting the budget for 2005/6 at the out-turn for 2004/5-(the low year), there was an apparent ‘overspend’ in intensive care. This highlighted the need to introduce a process into commissioning which would reassure the PCT that the expenditure on this activity was justifiable and in line with clinical need. The amount of time a patient spends in intensive care is individual to the patient. The routes and purposes for the use of intensive care are various as are the settings from which patients are drawn e.g. from other wards, theatre or A&E or transfers from other hospitals. Patients are also readmitted to intensive care. The purpose of focusing of length of stay from a commissioning perspective is to: • Set a reasonable length of stay in line with current practice. • Enable early warning to the commissioner of anticipated long stay patients and alert them to high cost cases. • Work with the Trust to find ways to reduce very long (and very costly) lengths of stay. It is proposed that the trigger length of stay for notifying the commissioner, for either Level 2 or Level 3 care, is 15 days of a protracted stay and again at 20 days for additional stays for the same patient. The PCT will need to: • Establish a process for receiving and analysing regular monitoring information from the trust. • Establish an alerting process when notified of long stayers by the trust • Agree a mechanism for liaison with the Trust over steps which might be taken to limit the length of Level 2 or Level 3 stays. 6. Key Risks In the development and delivery of this plan a number of key risks need to be highlighted and managed to ensure there are not unrealistic expectations on what can be achieved through effective referral management measures in short timescales and the programme is successfully delivered:- • Management capacity – The PCT is being restructured with a 15% management cost reduction. In addition there is a vacancy freeze to deliver a further saving due to the LDP financial position. This may reduce the PCT’s capacity for intensive programme / redesign management and the ability to deliver rigorous performance management. In addition, there is a shortage of experienced data analysts and business analysts. • Acute Trust Support – The success of the measures identified will reduce the PCT’s investment in its three main acute trusts and so impact on their financial positions. Unless there is further significant reduction in costs and 8 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • capacity of acute providers, there will be no overall improvement in the financial position of the NHS in London. For important delivery areas such as A&E redesign and reaching agreement on new to follow-up ratios, there is likely to be difficulty reaching joint positions with acute providers. • Support from StHA - In view of the likely tensions between commissioners and Acute providers, a clear and consistent approach will be required from the StHA to support the delivery of the plans. In view of the transition to a London StHA the potential for inertia needs to be recognised. • There are two specific areas where clarification from the StHA is required. Firstly the percentage that costs are withdrawn for reductions in unscheduled admission. If this is 50% for reductions below the PbR tariff threshold it will mean that the costs of alternative community services will be met but there will be no saving to the commissioners. Secondly clarity is required on outpatient new to follow up ratios so financial incentives are placed where they will drive service redesign. • Support from Practice Based Commissioning – Success in the demand management programme will need fully committed and operationally effective Practice Based Commissioning. They may not yet be fully able to deliver the changes needed in the current year. • Support from patients and the public. The changes are complex and could be misinterpreted by the public as restricting legitimate access. Good consistent communication is essential by all players, providers, clinicians, commissioners and politicians. • Further delays in delivery of the electronic patient record by Connecting for Health. 9 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • 7. Summary of Demand Management Programme for 2006/7 – 2007/8 Key Demand Cost Cost Director Risk Management Actions Management reduction reduction Lead Intervention / 2006/7 2007/8 Processes £000s £000s Scheduled Care New 91 182 Greg Discussions with PBC clusters outpatient Russell on appropriateness of top line referrals target rather than output from individual pathway redesigns Follow-up 219 657 Greg Directed Enhanced Service outpatient Russell used to explore patients with ongoing follow-ups and pathway redesign with PBC clusters Excluded 100 100 Chris Confirmation of exclusion procedures Watts protocols is underway, followed by audit of current practice and implementation of measures within primary and secondary care to improve compliance Reduction in 271 542 Chris The process for reducing these elective Watts high levels of activity against HRGs national benchmarks has not yet been clarified, and is being addressed with PBC clusters Unscheduled care A&E 122 TBC Greg Management of A&E redesign attendances pending Russell to implement front end triage model for and agreement of PBC managing clusters to provide alternate unschedule treatment sources in the d minors community Unscheduled 0 0 Greg 50% for reductions below the admissions (795 saving (795 saving Russell PBR tariff threshold it will at 50% is at 50% is mean that the costs of invested in invested in alternative community services intermediate intermediate will be met but there will be no care) care) saving to the commissioners. Clarity required through StHA Critical Care 213 0 Chris Ensuring reporting system and Watts clinical review processes are implemented Total 1,016 1,481 10 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • 8. Performance Management The PCT Local Delivery Plan / PCT annual business plan is currently being drafted and the effective referral management programme will form one the central domains of the PCTs activity in 2006/7. The key elements of performance management will be:- • Reporting • Monitoring Process • Lead PCT Director responsibility To enable delivery of rigorous performance management, a monthly delivery report is required and is under development as outlined in Appendices 2-4. Reporting will be as follows: - • Weekly Senior Executive Directors - Risk management and unlocking barriers to delivery • Monthly PBC steering group and PBC cluster board meeting • Monthly PCT PEC • Bi monthly PCT Board • Reporting to StHA to be confirmed Lead Director responsibility is identified in section 7 and each of the 7 Key Referral Management Interventions / Processes are being mapped into a project plan to be signed off by the PCT Board in June. 11 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Appendix1 Indicative Budget Management Plan (incorporating Effective Referral Management Programme) Area of Activity Rationale Target Key actions Evidence 12 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Primary prevention Influenza campaign “Insurance” measure To meet the DoH target Cluster to order Copy of orders to RB (links with Flu DES) contributing to of 70% vaccination of sufficient vaccine to admission avoidance in vulnerable patients achieve target outbreak / epidemic year Scheduled Care O/P 1st referral Variation in referral To reduce new O/P first Practices to receive Practice confirmation of rates within cluster appointments by 1% PCT provided report of receipt indicating differing activity 05-06 management strategies. Attendance at cluster Cluster discussion to Cluster discussion agenda’d discussion better understand the range and primary care alternatives O/P New : F/Up 05-06 activity showed To reduce new to F/UP Practices to receive Practice confirmation of 10% growth in follow up up ratio to 1:1 report on all patients receipt of report with nil growth in first receiving 2+ f / up in referrals. Primary & previous year Note review on record Community alternatives to secondary f/up may Review record and be indicated and could discuss alternative mgt provide care nearer to with patient. Eg where home. there is a community alternative (anti-coag) Excluded procedures PEC/PBC Steering No referrals for Practices to receive Practice confirmation of group has agreed excluded procedures copy of full list of receipt of list and consistent adoption of from primary care excluded procedures procedures excluded procedures and ETA procedure policy across Lewisham Agenda item of cluster but to implement Establish a Cluster meeting clinicians need to be based monitoring kept informed as to mechanism content of list and Exceptional Treatment Arrangements procedure 13 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Unscheduled Care A& E frequent National data suggests To reduce the number Practices to receive Practice confirmation of attendance co-morbidity and of attendances at A& E report of most frequent receipt of report alcohol use associated by 2% attenders at A&E (2+ with high A&E attends. visits) Note review on record Proactive mgt and discussion with patient Review mgt of either to plan care may move -Highest users or response to scheduled -Group where there is a care similarity eg alcohol related episodes 14 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Appendix 2 Monthly Performance Report – Key Lines of Reporting Primary Prevention Stopping smoking - Achieve the target of 1574 smoking quitters in 2006/7 Influenza vaccination - Achieve uptake for vaccination national target of 70% in 2006/7. Alcohol strategy and its implementation - Achieve alcohol screening of 80% of new registrations to 31 (LES) practices. Scheduled Care - (See Appendix 3) New Outpatient Referrals - Target reduction of 1% = 584 attendances / Cost reduction of £91K Follow-up Outpatients - Target reduction 2,774 attendances (growth level in 2005/6) / Cost reduction of £219K Excluded Procedures - Cost & Target Reduction in activity / £100K Reduction in Elective HRGs - Target reduction 5% = 226 procedures / Cost reduction of £271K • Musculo-skeletal PBC redesign – Reduction in referrals / elective procedures in secondary care tbc • Gynaecology PBC redesign - Reduction in referrals / elective procedures in secondary care tbc • Dermatology PBC redesign / Paediatric Dermatology - Reduction in referrals / elective procedures in secondary care tbc Unscheduled Care - (See Appendix 4) A&E Attends - Target reduction 2% = 2270 attendances / Cost reduction £25K Unscheduled Admissions - Target Reduction in activity 2006/7 6% (Total 696 patients) / Cost reduction £795K Critical Care - Target Reduction in activity 5% = 87 OBDs / Cost reduction £213K • Diabetes PBC redesign – Reduction in unscheduled admissions tbc • Sickle Cell redesign - Reduction in unscheduled admissions tbc • COPD / Heart Failure redesign - Reduction in unscheduled admissions and readmissions tbc 15 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Appendix 3 Scheduled Care Intelligence Kings/Guys/University Hospital Lewisham Key Pathway Information (By Provider/Specialty) No of New No of New Size of Waiting time Outpatient Diagnostic Conversion Elective Waiting List Length of Readmissio Outpatient Outpatient Outpatients Outpatient for Activity Waits / Rate to Procedures Size / Stay n Follow-up referrals placed on Waiting List Outpatient Activity Treatment + Waiting + + + waiting lists Appointment from National Time National National National Outpatient Benchmark Benchmark Benchmark Benchmark in Key Procedures Monthly Note: In addition, total number of referral to Primary Care alternatives for outpatients / minor procedures 16 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8
    • Appendix 4 Adult Unscheduled Care Intelligence University Hospital Lewisham Key Pathway Information Patients Ambulance Number Triage Patients 98% Number of Bench- UHL Medical Delayed Patients Patients Patients supported Transfers A&E Informatio diverted to Target Emergency marked Medical Outliers Discharge Discharged Discharged Re- by IC To attends n from Intermediate Admissions Attends to Patients to Inter- admitted following UHL by 5 A&E Care from admission LOS mediate home categories Project A&E ratio Care assess- ment (comm. adm. avoidance) Monthly Weekly Weekly Weekly Monthly Weekly Weekly 3 monthly Monthly Weekly Weekly Monthly Weekly Weekly Diana Richard Diana Barbara Barbara Richard Barbara Barbara Corrine Diana Barbara Barbara Susman Partin Susman Tringham Tringham Partin Tringham Tringham Moocarm Susman Tringham Tringham e Barbara Tringham Analysis of where from Walk in Centre attends ?Coding Issues 3/6 Weekly Different monthly Code Richard Simon Partin Gosney 17 11/11/2010 Effective Referral Management Programme 2006/7 – 2007/8