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  1. 1. Cantilever House Eltham Road Lee London SE12 8RN Switchboard 020 7206 3200 Direct line 020 7206 3371 Fax 020 7206 3251 Email: 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  2. 2. • 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  3. 3. • 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  4. 4. 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 on Trust 2005/6 Plan Outturn 2005/6 Plan Outturn M11 UHL Activity 37,446 Value £4,606,232 Activity 37,433 Value £4,587,534 Activity 71,638 Value £6,312,803 Activity 77,360 Value £6,832,710 M10 King’s Activity 11,724 Value £1,526,980 Activity 11,512 Value £1,535,101 Activity 16,864 Value £1,196,670 Activity 20,237 Value £1,436,004 M9 Guy’s Activity 8,837 Value £1,704,708 Activity 9,535 Value £1,804,216 Activity 21,017 Value £2,186,521 Activity 23,016 Value £2,363,621 Totals Activity 58,007 Value £7,837,920 Activity 58,480 Value £7,926,851 Activity 109,519 Value £9,695,994 Activity 120,613 Value £10,632,335 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  5. 5. 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 having anomalously high activity, where alternative pathway management may produce savings on hospital care. 5 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  6. 6. For these specialities, the following table shows a summary of the potential savings (episodes relating to specific HRGs only) Specialty Lewisham episodes Expected episodes Excess episodes Potential APC saving (£) Oral Surgery 291 122 169 112736 Dermatology / Plastic surgery 836 122 714 996083 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  7. 7. 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  8. 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. 8 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  9. 9. • 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 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  10. 10. 7. Summary of Demand Management Programme for 2006/7 – 2007/8 Key Demand Management Intervention / Processes Cost reduction 2006/7 £000s Cost reduction 2007/8 £000s Director Lead Risk Management Actions Scheduled Care New outpatient referrals 91 182 Greg Russell Discussions with PBC clusters on appropriateness of top line target rather than output from individual pathway redesigns Follow-up outpatient 219 657 Greg Russell Directed Enhanced Service used to explore patients with ongoing follow-ups and pathway redesign with PBC clusters Excluded procedures 100 100 Chris Watts Confirmation of exclusion protocols is underway, followed by audit of current practice and implementation of measures within primary and secondary care to improve compliance Reduction in elective HRGs 271 542 Chris Watts The process for reducing these high levels of activity against national benchmarks has not yet been clarified, and is being addressed with PBC clusters Unscheduled care A&E attendances 122 TBC pending model for managing unschedule d minors Greg Russell Management of A&E redesign to implement front end triage and agreement of PBC clusters to provide alternate treatment sources in the community Unscheduled admissions 0 (795 saving at 50% is invested in intermediate care) 0 (795 saving at 50% is invested in intermediate care) Greg Russell 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. Clarity required through StHA Critical Care 213 0 Chris Watts Ensuring reporting system and clinical review processes are implemented Total 1,016 1,481 10 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  11. 11. 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 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  12. 12. Appendix1 Indicative Budget Management Plan (incorporating Effective Referral Management Programme) Area of Activity Rationale Target Key actions Evidence Primary prevention Influenza campaign (links with Flu DES) “Insurance” measure contributing to admission avoidance in outbreak / epidemic year To meet the DoH target of 70% vaccination of vulnerable patients Cluster to order sufficient vaccine to achieve target Copy of orders to RB Scheduled Care O/P 1st referral Variation in referral rates within cluster indicating differing management strategies. Cluster discussion to better understand the range and primary care alternatives To reduce new O/P first appointments by 1% Practices to receive PCT provided report of activity 05-06 Cluster discussion Practice confirmation of receipt Attendance at cluster agenda’d discussion O/P New : F/Up 05-06 activity showed 10% growth in follow up with nil growth in first referrals. Primary & Community alternatives to secondary f/up may be indicated and could provide care nearer to home. To reduce new to F/UP up ratio to 1:1 Practices to receive report on all patients receiving 2+ f / up in previous year Review record and discuss alternative mgt with patient. Eg where there is a community alternative (anti-coag) Practice confirmation of receipt of report Note review on record Excluded procedures PEC/PBC Steering group has agreed consistent adoption of excluded procedures policy across Lewisham but to implement clinicians need to be kept informed as to content of list and Exceptional Treatment Arrangements procedure No referrals for excluded procedures from primary care Practices to receive copy of full list of excluded procedures and ETA procedure Establish a Cluster based monitoring mechanism Practice confirmation of receipt of list and procedures Agenda item of cluster meeting 12 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  13. 13. Unscheduled Care A& E frequent attendance National data suggests co-morbidity and alcohol use associated with high A&E attends. Proactive mgt and discussion with patient to plan care may move response to scheduled care To reduce the number of attendances at A& E by 2% Practices to receive report of most frequent attenders at A&E (2+ visits) Review mgt of either -Highest users or -Group where there is a similarity eg alcohol related episodes Practice confirmation of receipt of report Note review on record 13 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  14. 14. 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 14 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  15. 15. Appendix 3 Scheduled Care Intelligence Kings/Guys/University Hospital Lewisham Key Pathway Information (By Provider/Specialty) No of New Outpatient referrals + National Benchmark No of New Outpatients placed on waiting lists Size of Outpatient Waiting List Waiting time for Outpatient Appointment Outpatient Activity Diagnostic Waits / Activity Conversion Rate to Treatment from Outpatient Elective Procedures + National Benchmark Waiting List Size / Waiting Time Length of Stay + National Benchmark in Key Procedures Readmissio n Outpatient Follow-up + National Benchmark Monthly Note: In addition, total number of referral to Primary Care alternatives for outpatients / minor procedures 15 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8
  16. 16. Appendix 4 Adult Unscheduled Care Intelligence University Hospital Lewisham Key Pathway Information Patients supported by IC following home assess- ment (comm. adm. avoidance) Ambulance Transfers To UHL Number A&E attends by 5 categories Triage Informatio n from A&E Project Patients diverted to Intermediate Care from A&E 98% Target Number of Emergency Admissions Bench- marked Attends to admission ratio UHL Medical Patients LOS Medical Outliers Delayed Discharge Patients Discharged to Inter- mediate Care Patients Discharged Patients Re- admitted Monthly Weekly Weekly Weekly Monthly Weekly Weekly 3 monthly Monthly Weekly Weekly Monthly Weekly Weekly Diana Susman Analysis of where from Barbara Tringham Walk in Centre attends Richard Partin Diana Susman Barbara Tringha m Barbara Tringham Richard Partin Barbara Tringham Barbara Tringham Corrine Moocarm e Diana Susman Barbara Tringham Barbara Tringham 3/6 monthly Weekly ?Coding Issues Different Code Richard Partin Simon Gosney 16 29/01/2015 Effective Referral Management Programme 2006/7 – 2007/8