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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:-

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Effective Referral Management Programme 2006/7 – 2007/8

mailto:[email protected]

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.

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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 9,122MTarget 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.

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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 37,446Value £4,606,232

Activity 37,433Value £4,587,534



M10 King’s Activity 11,724Value £1,526,980




M9 Guy’s Activity 8,837Value £1,704,708




TotalsActivity 58,007Value £7,837,920



Activity 120,613Value £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.

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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.

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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 community alternatives to secondary care follow-ups in the following areas linked to the HRG analysis:

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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

Baseline activity 1749 Occupied Bed Days / Cost & Target Reduction in activity 5% = 87 OBDs / Cost reduction £213K

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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 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

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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.

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7. Summary of Demand Management Programme for 2006/7 – 2007/8

Key Demand ManagementIntervention / Processes

Cost reduction 2006/7£000s

Cost reduction2007/8£000s

Director Lead

Risk Management Actions

Scheduled CareNew 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 careA&E attendances

122 TBC pending model for managing unscheduled 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

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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.

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Appendix1 Indicative Budget Management Plan (incorporating Effective Referral Management Programme)

Area of Activity Rationale Target Key actions EvidencePrimary 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

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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

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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

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Appendix 3 Scheduled Care IntelligenceKings/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

Readmission

Outpatient Follow-up

+National

Benchmark

Monthly

Note: In addition, total number of referral to Primary Care alternatives for outpatients / minor procedures

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Appendix 4 Adult Unscheduled Care IntelligenceUniversity Hospital Lewisham

Key Pathway Information

Patientssupported

by ICfollowing

homeassess-

ment (comm.

adm. avoidance)

AmbulanceTransfers

ToUHL

Number A&E

attendsby 5

categories

Triage Informatio

n from A&E

Project

Patientsdiverted to

Intermediate Care from

A&E

98%Target

Number of EmergencyAdmissions

Bench-marked

Attends to admission

ratio

UHL Medical Patients

LOS

Medical Outliers

Delayed Discharge

Patients Discharged

to Inter-mediate

Care

Patients Discharged

PatientsRe-

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 Tringham

Barbara Tringham

Richard Partin

Barbara Tringham

Barbara Tringham

Corrine Moocarm

e

Diana Susman

Barbara Tringham

Barbara Tringham

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3/6 monthly

Weekly

?Coding Issues

Different Code

Richard Partin

Simon Gosney

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