1. WHSSC REFERRAL MANAGEMENT

2. Guidance Aims and objectives of referral management
Guidance to using directory

3. Background Information
On behalf of the Local Health Boards WHSSC manages thirty four healthcare contracts, with English providers to the value of £100m.
Approximately 16,000 new out-patient referrals made to these contracts per annum.

4. Aim
To introduce a formal process of approving all new outpatient referrals for all patients requiring treatment at a defined list of English NHS provider organisations contracted through the Welsh Health Specialised Services Committee (WHSSC).

5. Principles - 1
Where appropriate patients from Wales are treated in Wales and at established centres close to the border;
Local services are engaged whenever possible, and referrals into England specialist centres are robustly managed;
Requests for specialist and non-specialist services are considered by the appropriate commissioner ensuring equity of access;
Patients receiving specialist care in England are treated in the preferred providers;
The specialist and tertiary centres that serve the population of Wales are sustained;

6. Principles - 2
There is an improvement in intelligence with regards to new outpatient referrals;
Arrangements and mechanisms that would improve service and commissioning planning, both in Wales and outside, are in place; and
Clinical Governance arrangements are in place through contract mechanisms which will allow for the audit the quality of care and outcomes for patients.
There will be no undue delay to patient care as a result of the introduction of referral management;
Clinical gateways are empowered to make referrals into England where the service cannot be provided within Wales

7. Phase One Providers Phase one Providers (Specifically non border):
Cambridge University Hospital NHS Foundation Trust (Addenbrooke's)
Great Ormond Street Hospital NHS Trust
Guy's and St Thomas' Hospital Trust
Imperial College Healthcare (Hammersmith)
Kings Healthcare NHS Trust (King's College Hospital NHS Foundation Trust)
Leeds Teaching Hospitals NHS Trust
Papworth Hospital NHS Trust
Royal Brompton and Harefield NHS Trust
Royal Free Hampstead NHS Trust
Royal Marsden NHS Trust
Royal Orthopaedic Hospital NHS Trust
Sheffield Teaching Hospitals NHS Trust
University Hospital North Staffordshire NHS Trust
University College London Hospitals NHS Trust

8. Process of Referral Management - 1
Referrals will be managed using one of three discrete gateway points:
Clinical gateways – Clinically informed decisions made regarding the appropriate management of referrals in accordance with current policies.
WHSSC Prior Approval gateway - Where no a clinical gateway is in place for a particular specialised service, the WHSSC prior approval team will provide the necessary authorisation.
LHB Prior Approval - Where a referral is for a non specialist service within a WHSSC contract, the relevant LHBs prior approval team will provide the necessary authorisation

9. Process of Referral Management - 2
Every clinical gateway /prior approval team is registered with WHSSC and issued with a gateway number and WHSSC approval stamp.
All new out-patient referrals into the first phase English providers must be stamped in order for the receiving Trust to process the referral.
Any referral that is not stamped will be returned to the referrer.
Unless the secondary care consultant/GP transfers the care of the patient to the clinical gateway, clinical care and responsibility remains with the secondary care consultant/GP.

10. Process of Referral Management - 3
If the clinical gateway does not authorise the referral and the secondary care consultant / GP disagrees with this opinion, the secondary care consultant can apply to WHSSC for authorisation on an exceptional basis in accordance with the All Wales policy on making individual decisions.
It is a requirement that any urgent referrals are processed within 2 working days and routine referrals processed within 10 working days.

11. Process of Referral Management - 4
None of the above should result in a delay to patient care. Where the position is unclear, the default position will always be for the referral to be considered by the WHSSC Prior Approval team.

12. Process of Referral Management -5
To support the process WHSSC has produced a comprehensive service directory which will inform referrers of the following:
Definitions of services
Relevant policies and or service specifications relating to services
Specific inclusions/exclusions where appropriate
Authorised gateways and gatekeepers
Preferred providers

13. Referral Management Service Directory
WHSSC

14. Objective
Developed to support the tertiary referral management project.
Single point of information including:
Services commissioned through WHSSC
List of local tertiary providers
Referral management arrangements
AGNSS services
WHSSC commissioning policies

15. Structure Excel spreadsheet Index page with 8 subsections
Guidance on using document
Service Definitions
Local Tertiary Providers
Referral Management
AGNSS Services
AGNSS Providers
Commissioning Policies
DH Specialised Services Definition

16. Service Definitions
High level definitions of specialised services commissioned by WHSSC
Unique reference number.
Definition group – Broad level definition.
Specific service area – service specific definition.
Commissioning arrangements since 2009/10
Planning exclusions and inclusions
Funding exclusions and inclusions
Referral management
Services which are highlighted in light grey are not delegated to WHSSC, and as such are planned and funded locally by each Health Board.

17. Local Tertiary Providers
Current local service provision for each of the services identified in the previous section
Clinicians should consult this section to identify the arrangements for provision of this care within the existing contractual arrangements held by NHS Wales

18. Referral Management 1
Clinicians should consult this section once all levels of local services have been exhausted, in order to identify the clinical gatekeeping arrangements.
If the diagnosis or required procedure is not included, then the clinician will need to liaise with appropriate IPFR team.

19. Referral Management 2 Diagnosis ICD code – where available Procedure
OPCS4 code – where available
Health Board – these are the health board populations which are covered by the referral management arrangements
Clinical gatekeeper – the name of the designated gatekeeper
Provider – the provider which provides the care or specific procedure for the identified diagnosis
Sub specialty – the subspecialty at the provider which patients are referred to through the gatekeeper
Gateway number – the assigned number for each gateway

20. AGNSS
Two sections
Services
Providers

21. Additional Resources List of WHSSC policies
Links to DH Specialised Definitions Set

22. How to use Directory 1 Directory is designed to be used sequentially
Buttons on the index sheet link to the relevant section

23. How to use Directory 2
For example, clicking on the service definition button, as below

24. How to use Directory 3
Will open the Service Definition Section as illustrated below

25. How to use Directory 4
Clicking on the return to Index button, will return to the Index sheet

26. Support Directory will be available on WHSSC website
Updates will be uploaded as further gatekeeping arrangements are established
All queries relating to the Directory should be directed to