Presentation on theme: "NHS Q.I. Elective Demand Management in Pennine Lancashire"— Presentation transcript:
1NHS Q.I. Elective Demand Management in Pennine Lancashire [add your organisations logo here]NHSQ.I.Elective Demand Management in Pennine LancashireDr Malcolm Ridgway Vice Chair of Blackburn with Darwen CCGA celebration of those ‘light bulb moments’ that are transforming patient experience and care across the North West
2OverviewA strategy and action plan has been developed to reduce elective demand management in Pennine Lancashire. The key elements are;Peer review of referralsEducationShared decision makingSoftware decision supportInterventions of limited clinical priorityAlternative providers (GPwSIs, minor surgery)NHSQ.I.
3Referral 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 producedRefined following joint work with AQUA and the SHAPrioritised implementation plan then producedNHSQ.I.
4There 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 avoidablethere are patients who need a referral but may fail to receive onea large number of patients currently referred to secondary care could be seen alternative settingsa considerable number of referral letters lack the necessary informationthere is frequently no shared understanding of the purpose of the referral among the GP, the patient and the consultantthe appropriate investigations have not always taken place prior to referral.“ Referral management: lessons for success - The King’s Fund 2010”NHSQ.I.
5Referral Management – Key Principles; Referral Demand Management dependant on improved Referral QualityEvidence shows that Peer Review is key to improving Referral Quality;Review of referral dataReview of referral letters (internally or externally)Any system has to be slick, quick, evidence based, improve referral behaviour, cost effective, sustainableNHSQ.I.
6Data ReviewThe is significant variation in referral behaviour between GPsEven allowing for similar demographics and disease prevalenceThere is variation in the variation eg between specialitiesYou do not know what you do not knowNHSQ.I.
7NHS Q.I. Referrals Review Local – within the practice (QP6) External – between practices (QP7)External – Consultant or GPwSI triageEducation and timely feedback required to improve quality and change behaviourNHSQ.I.
8Grouping potential interventions Potential interventions grouped according to their possible impact and implementation rating (as per AQuA):High /med impact and easier implementationHigh/med impact but harder to implementMed impact and easy /med implementationLow impact / harder to implement
9Grouping potential interventions HIGHERShared Decision MakingReferral peer review and FeedbackStructured referral systemsPatient Decision AidsValue Based CommissioningGP EducationEASIERIMPLEMENTATIONClinical Referral GuidelinesClinical Assessment and TriageUndifferentiated restrictions on access to low value careReferral Management CentresFinancial IncentivesIMPACTLOWER
10Specific Interventions and the Pennine Lancashire Approach Peer Review and QoF GreenUtilisation of updated QoF targets for referral reviews and pathway implementation (elective component)Year 1internal practice review and reportLarge event for groups of practices to discuss, collated ideas and information, developed the 3 pathways for implementationYear 2Internal practice review – different specialities, report to CCGPractice “groupings” formed to discuss referrals and joint working, report to CCGPathways to be developed for implementationNHSQ.I.
11Specific Interventions and the Pennine Lancashire Approach Peer Review ctdConsultants and others role – “joint accountability for demand management”Ongoing practice referral review – locums, registrars, nurse practitioners, as part of CPDNHSQ.I.
12Specific Interventions and the Pennine Lancashire Approach Structured Referral Systems GreenReferral 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 slickProblems with location, uploading to GP systems, updating etcMap of Medicines?IT referral management systemsRF Pathfinder, Arezzo, MoM, Isabel, McKessonIssues of integration, time, clunkiness, appropriateness, customisation workload, cost etcPotentially the “Holy Grail” of the futureNHSQ.I.
13Specific Interventions and the Pennine Lancashire Approach Shared Decision Making and Decision Aids GreenStrong evidence base for effectiveness though harder to implementDecision Aids (Amber) currently on NHSD site eg Hip and Knee OA, Cataract. Medium impact, easy to implement.Informed patients make the decision – usually about interventionsCourses for train the trainer in November and into next year – protected time.NHSQ.I.
14Specific Interventions and the Pennine Lancashire Approach Advice Services Green?Already integral part of CaB – free!Intermittently used and supportedMany referrals not now sent via CaBFormalised Advice servicesTariff to be agreed (?£20-30)Systematic reliable processStructured advice form/guide – all required data presentUse of CaB to track and monitorUseful in “complex” specialities eg renal, haematology, cardiologyNHSQ.I.
15Specific Interventions and the Pennine Lancashire Approach Referral Gateways RedLow impact – deskill and annoy GPs, inconvenience patients, sustainability, costReasonably easy to implement – CaB, bespoke softwareSeen as a “Quick fix”Early gains - being watched!Education key for quality improvement and sustainabilitySome use referral proformasNHSQ.I.
16Specific Interventions and the Pennine Lancashire Approach Advice and Navigation LES Amber?Panel of GPs and GPwSIs – CCG sessional rates4 specialities - high demand areas and or alternative providers;General surgeryRheumatologyDermatologyOrthopaedicsSmall payment to practices for increased bureaucracyAdvisory onlyUtilises CaB system – “free”, good reporting, panel can use at homeNHSQ.I.
17Specific Interventions and the Pennine Lancashire Approach Clinical Referral Guidelines RedLittle evidence of efficacyStored and lost – rarely used sustainablyVariable formats - paper, electronicOften out of date – or using older versionsSome have referral forms – paper!, variable formatMap of Medicines, Mentor?ClunkyNot quick and slickUseful for later reference, learning, PDP etcNHSQ.I.
18Specific Interventions and the Pennine Lancashire Approach Interventions of Limited Clinical Priority Amber?Lancashire wide initiative“Principles of Commissioning” devised and agreedWide involvement of public health, GPs, Consultants, Nurses, publicEvidence based (NICE, SIGN) or “cosmetic”Many already in force eg tattoo removal, reversal of sterilisationGuidance available eg Tonsillectomy, Grommets, HysterectomyComplementary therapiesNot an absolute ban – some room for interpretation eg skin tags can be removed if causing “discomfort”Have to be agreed and implemented by all providersNHSQ.I.
19Specific Interventions and the Pennine Lancashire Approach Education GreenGolden thread to improve quality and sustainabilityPart of referral review processProtected Learning TimeBwD has 9 afternoon sessions per yearStrong clinical focusCurriculum guided by CCG (demand management initiatives, QoF, quality/variation, CPDs)NHSQ.I.
20Specific Interventions and the Pennine Lancashire Approach Interventions that are “out” RED!!Financial incentivesDH outlawedUnethicalReduce qualityCCGs and GPs open to probity complaintsRationingStill sufficient “waste” in the systemHow do you choose what to ration? Public vs Clinical view?Issues with inequality and discrimination (smokers, overweight, race, gender etc)NHSQ.I.
21NHS Q.I. Summary Referral Demand Management is about; Quality improvementPeer ReviewEducationUsing the best evidence (clinical and methodology)Quick and slick processes (2 minute window)Integrated real time IT decision support probably the futureNHSQ.I.
22NHS Q.I. Thank you – Questions? Links; firstname.lastname@example.org Dr Malcolm RidgwayClinical Director for Quality and EffectivenessVice Chair Blackburn with Darwen CCGNHSQ.I.