PCTs and the intermediate tier (Pursuing a primary care led NHS) Dr Martin Connor Associate Director (Health Reform) Greater Manchester Strategic Health Authority Nov Future Healthcare Networks

Modernisation and Performance Improvement: A Strategic Framework for Access (A System Model) Optimise Bed Occupancy Intermediate Care Unscheduled Care Elective Care Sector Structured Management of Demand Strategic Goals Policy Possibilities Aligning Capacity and Demand Develop Community Infrastructure Streaming Utilisation review EC Networks Tier 2 Primary Care Elective Re-design & DTCs 1 o /2 o Service Interface CLINICAL GOVERNANCE & PATIENT SAFETY WORKFORCE INFORMATION & TECHNOLOGY CHRONIC DISEASE MGT PUBLIC & PATIENT INVOLVEMENT Primary Care Advanced Access Network to Develop

Beds & Theatres Outpatients Primary care Community Nested Capacity

Limited Threshold Management Standard Primary Care Management Standard Acute Care Management Management by Self Care and Prevention T1 T2 Disease Severity Progression over time

Threshold Management Primary Care Tier 1 Acute Care Primary Care Tier 2 Management by Self Care and Prevention T1 T2 T3 Disease Severity Progression over time admission Therapeutic Drive

LDP elective strategy (with delivery programmes) 0% growth in GP referrals to outpatients (RBMS & Tier 2) 3% growth in elective activity through productivity and efficiency (GM Choice, POA programme, new performance management focus on system measures) 3/2/1% growth over three year period in new outpatient activity (Combined with 0% growth in referrals, to reduce backlog then bring the system towards balance)

Building new capability Tier2 – developing a broader range of choice closer to the patient Booking services – managing the referral pathways through primary and secondary care Greater Manchester Choice Centre – coordinating the capacity in secondary services Greater Manchester Surgical Centre – providing additional surgical capacity Clinical networks – involving clinicians in reform of pathways

TIER 2: Proposed further £10m over 3 years - £14m total Three waves: £4m Jan 2004 (£1m in year effect) £4m April 2004 £2m Jan 2005 (+ £3m investment in infrastructure…)

Referral Management RBMS and Tier 2

PCT Referrals Management Service Proposal The previous situation Capture Conversion Booking Primary Care Request OP Referral Book OP appt Most referrals Acute Trust based

GMEB – Planned process for majority of referrals Capture & Convert Conversion to Outpatient registration on PAS Booking Primary Care Request Book OP appt PCT BasedAcute Trust

Capture & convert to electronic document Tier 2 Discussion & Direction ConversionBooking Primary Care Request OP Referral, Diagnostic request, back to GP Book OP appt or diagnostic test PCT Based GMEB – RBMS Aims

FUNDAMENTAL DISTINCTION WAITING LISTSCHEDULE Patients who have been seen and for whom it is decided further treatment or contact is required Those who are not linked to an agreed future date, time and location Those who are linked to an agreed future date, time and location

HOSPITAL TRUST TREATMENT SCHEDULE (Non-standard, unbooked, high cancellations, difficult to monitor) Each Trust operates a treatment schedule Patient flow

HOSPITAL TRUST TREATMENT SCHEDULE (Non-standard, unbooked, high cancellations, difficult to monitor) Patient flow WAITING LIST [OP/IP/DC] But the WL is typically greater than the schedule can accommodate

HOSPITAL TRUST TREATMENT SCHEDULE (Non-standard, unbooked, high cancellations, difficult to monitor) Patient flow WAITING LIST [OP/IP/DC] Waiting list initiatives, private practice So the Trust flexes the schedule via reactive means: WLIs and Private Practice

HOSPITAL TRUST TREATMENT SCHEDULE (Non-standard, unbooked, high cancellations, difficult to monitor) Patient flow WAITING LIST [OP/IP/DC] Waiting list initiatives, private practice But… where are the PCTs in all this, and how could they help tackle waiting lists?

HOSPITAL TRUST 6 MONTH TREATMENT SCHEDULE Patient flow New model of patient flows: patients retained in hospital systems only when schedules can guarantee treatment within waiting times; otherwise, PCT uses referrals management to directly broker choice of alternative provision PRIMARY CARE TRUST TIER 2 TREATMENT SCHEDULE GMSC TREATMENT SCHEDULE DTC TREATMENT SCHEDULE PLURAL PROVISION EXCESS WAITING Referrals Management Plural Provision

Benefits of PCT-led choice: Enhances patient experience – not left hanging around with no contact Provides means to offer alternative treatment With RBMS, provides PCTs with means to monitor present activity across the whole system and build alternative pathways of care Repersonalises the waiting list – we respond to long waiters more individually Incorporates dynamic, rather than reactive, validation of lists Provides means by which we can work towards zero suspensions Attacks waiting list volume and improves list quality by activating ROTTs (up to 25% in some specialities) before POA Begins to clarify Trust capacity within the three month schedule – the 2008 end point Provides early warning about developing waiting list problems/ gaps in capacity Stimulates development of plural provision

Closing messages In the NHS Plan, booking replaces waiting lists, and this needs to be in the front of our minds Successful booking strategies need to tackle the issue of referrals management as a distinct but essential part of the change A low wait NHS will focus on the rate, and distribution of demand as well as on capacity to meet demand Because of this, commissioning as a PCT function becomes of paramount importance to build plural provision The talk is often of the risk to hospital stability of financial flows – but what of the risks to PCTs, where the resource limit lies We can use new communications technology and patient choice to drive change whilst improving quality