Elective Demand Management in Pennine Lancashire

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• 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)

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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

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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
  Kings Fund 2010

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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

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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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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

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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
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Grouping potential interventions
HIGHER
Shared Decision Making
Referral peer review and Feedback
Structured referral systems
Patient Decision Aids
Value Based Commissioning
GP Education
IMPLEMENTATION
EASIER
Clinical Referral Guidelines
Clinical Assessment and Triage
Undifferentiated restrictions on access to low
value care
Referral Management Centres
Financial Incentives
IMPACT
LOWER
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Specific Interventions and the Pennine Lancashire
Approach

• Peer 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

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Specific Interventions and the Pennine Lancashire
Approach

• Peer Review ctd
• Consultants and others role joint
  accountability for demand management
• Ongoing practice referral review locums,
  registrars, nurse practitioners, as part of CPD

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Specific Interventions and the Pennine Lancashire
Approach

• Structured 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

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Specific Interventions and the Pennine Lancashire
Approach

• Shared 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.

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Specific Interventions and the Pennine Lancashire
Approach

• Advice 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

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Specific Interventions and the Pennine Lancashire
Approach

• Referral 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

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Specific Interventions and the Pennine Lancashire
Approach

• Advice 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

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Specific Interventions and the Pennine Lancashire
Approach

• Clinical 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

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Specific Interventions and the Pennine Lancashire
Approach

• Interventions 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

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Specific Interventions and the Pennine Lancashire
Approach

• Education 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)

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Specific Interventions and the Pennine Lancashire
Approach

• Interventions 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)

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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

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Thank you Questions?

• Links
• m.ridgway_at_nhs.net
• http//www.bwd.nhs.uk/policies-and-procedures/poli
  cies-of-limited-clinical-value/
• Dr Malcolm Ridgway
• Clinical Director for Quality and Effectiveness
• Vice Chair Blackburn with Darwen CCG