Specialised Services: CPL-008 Referral Management Policy

Transcription

1 Specialised Services: CPL-008 Referral Management Policy 2017 Version 2.0

2 Document information Document purpose Document name Policy Referral Management Policy Author Welsh Health Specialised Services Committee Publication date 2017 Document No CPL-008 Review Date 2020

3 Contents 1. Introduction Scope Policy Statement Aims and Objectives Referral Management Arrangements Key Elements Clinical Gatekeepers Responsibilities WHSSC Medical Director Clinical Gatekeeper All Wales Individual Patient Funding Request Panel Resources Training Equality Policy Compliance Resources References/Further Information Distribution Review... 9

4 1. Introduction Local Health Board (LHB) in Wales are accountable, through their statutory responsibilities, to efficiently and effectively use all resources to plan, fund, design, develop and secure the delivery of primary, community, in-hospital care services and specialised services for their population. The challenge to NHS Wales is to ensure that the highest quality care is delivered for all Welsh patients, within the finite resources available. Welsh Health Specialised Services Committee (WHSSC) is a joint committee which brings each of the seven Health Boards together to ensure that there is a shared national approach to the planning and provision of specialised services for the population of Wales. Our strategic aim is, on behalf of the Health Boards, to ensure that there is equitable access to safe, effective and sustainable specialist services for the people of Wales, as close to patients homes as possible, within available resources. This policy has been developed to support the Referral Management Process. Referral Management is one of the processes used by WHSSC to facilitate, monitor and manage the referral of Welsh patients to specialist healthcare providers in NHS England where a contract is held between WHSSC and the provider organisation. The Referral Management process ensures patients who can be treated in Wales are treated in Wales and where a specialist service cannot be provided in Wales that consideration is given to referring that patient to an appropriate NHS healthcare provider. The process will support and ensure that: the specialist and tertiary centres that serve the population of Wales are sustained training, skills and continuous professional development of NHS Wales staff is maintained local services are engaged whenever possible, and referrals into England specialist centres are robustly managed where non-specialist care is required the patient is repatriated back to local secondary care services in Wales arrangements and mechanisms that would improve service and commissioning planning, both in Wales and outside, are in place, and 4

5 clinical governance arrangements are in place through contract mechanisms which will allow for the audit of the quality of care and outcomes for patients. 2. Scope This policy only applies to the referral of patients to healthcare providers in NHS England where WHSSC hold a contract. 3. Policy Statement The WHSSC Referral Management policy supports and aims to ensure that: there is equity of access to services for all Welsh patients Welsh patients are treated within Wales where clinically appropriate requests for specialist and non-specialist services are considered by the appropriate commissioner in Wales patients receiving specialist or non-specialist care in England are treated by designated healthcare providers where contract monitoring mechanisms are in place healthcare funding, where appropriate, stays in Wales to sustain and develop Welsh healthcare services there are mechanisms to monitor and audit patient flows to designated healthcare providers WHSSC only pays for services that have been delegated to it by the LHBs and that have been approved for funding. 4. Aims and Objectives The aims and objectives of Referral Management are: ensure equity of access across Wales to specialist services in England sustain specialist and non-specialist services in tertiary centres located in Wales and also in England where contracts are in place to serve the North and border populations of Wales endeavour to ensure patients wherever possible are treated closer to home ensure that the referral process is as streamlined as possible provide WHSSC with timely information on specialist referral activity and flows, and manage referrals within a commissioning framework by commissioning only from preferred specialist centres in England, and by doing so improving the audit of outcomes and management of service procurement ensure the quality of care for patients 5

6 ensure that patients follow the appropriate pathways for treatment. 5. Referral Management Arrangements 5.1 Key Elements The key elements of Referral Management are: designation of Clinical Gatekeepers these are preferred clinicians who, on behalf of WHSSC, are authorised to refer and commit WHSSC funding for treatment at preferred specialist centres outside Wales where no clinical gateways are in place, referrals will be authorised by either the WHSSC or Local Health Board prior approval team preferred centres in England appropriate contracting arrangements will be in place between WHSSC and the preferred centres establishment of agreed referral pathways, consistent commissioning and service specification, policies and access criteria, with a view to ensuring equity of access across the Welsh population in exceptional cases applications for funding at a non-preferred centre can be made in line with the All Wales Policy: Making Decisions on Individual Patient Funding Requests (IPFR) repatriation of patients where clinically appropriate. Once the specialist Referral Management System is fully introduced, only referrals managed through this system will be accepted by English Trusts and funded by WHSSC. English Trusts will return all unauthorised referrals to the original referrer requesting authorisation be sought from the responsible commissioner. 5.2 Clinical Gatekeepers The Clinical Gatekeeper is the nominated clinician through whom all designated elective non urgent specialist referrals pass. The preferred clinician will receive referrals from colleagues and assess whether the care can be provided within Wales, and within existing WHSSC Commissioning and service specification policies. If treatment outside of Wales is required the Clinical Gatekeeper is authorised to commit funding on behalf of WHSSC, provided it is within commissioning policies and to an English provider where an existing contractual arrangement is in place.). Clinical Gatekeepers will: be a specialist tertiary clinician have knowledge of the capabilities of the services in Wales 6

7 have knowledge of services and capabilities of the services outside of Wales, and be aware of relevant WHSSC commissioning policies and service specifications. The agreed list of clinical gatekeepers is available at 6. Responsibilities 6.1 WHSSC Medical Director The WHSSC Medical Director of is the lead officer for referral management and is responsible for: leading and managing all aspects of the referral management process approving specialised referrals where there is no clinical gateway in place identifying the need for additional clinical gateways ensuring that patients are repatriated where clinically appropriate liaising with Local Health Boards in order to address any issues arising from the validation process ensuring that all relevant documentation is updated onto the WHSSC website reporting Progress to the Joint Committee. 6.2 Clinical Gatekeeper The role of the Clinical Gatekeeper is to: review and approve new out-patient referrals for assessment and referral to preferred specialist centres management of the referral process providing pre specified monthly referral information in the agree format advising on amendments to the list of preferred providers, and participate in annual audit. It is important to note that unless the secondary care clinician transfers the care of the patient to the Clinical Gatekeeper, clinical care and responsibility remains with the secondary care clinician. 6.3 All Wales Individual Patient Funding Request Panel If the Clinical Gatekeeper or Prior Approval Team does not authorise the referral, and the secondary care clinician disagrees with this opinion the secondary care clinician can complete an Individual Patient Funding Request (IPFR) form and on the form clearly provide information as to 7

8 why funding should be provided on the basis of exceptionality. Having sought an opinion from the gatekeeper and other external bodies, the request will be considered at the Local health Board or All Wales IPFR Panel depending on the nature of the referral. Further information regarding the All Wales Policy: Making a Decision on Individual Patient Funding Requests (IPFR) can be found on the WHSSC website: 7. Resources Resources will be required to purchase the gatekeeper authorisations stamps for phase 1 of implementation. Staffing resources will also need to be identified and agreed for maintenance and further role out of Referral Management. The Executive Lead for Referral Management will be the Director of Nursing and Quality Assurance. 8. Training Guidance documents including frequently asked questions will be developed and made available on the WHSSC website. 9. Equality The Equality Impact Assessment (EQIA) process has been developed to help promote fair and equal treatment in the delivery of health services. It aims to enable Welsh Health Specialised Services Committee to identify and eliminate detrimental treatment caused by the adverse impact of health service policies upon groups and individuals for reasons of race, gender re-assignment, disability, sex, sexual orientation, age, religion and belief, marriage and civil partnership, pregnancy and maternity and language (Welsh). This policy has been subjected to an Equality Impact Assessment. The Assessment has shown that there will be no adverse effect or discrimination made on any individual or particular group. 10. Policy Compliance A clinical audit and evaluation will be undertaken six months following the introduction and implementation of phase 1 of the Referral Management project. 8

9 11. Resources Resources will be required to purchase the gatekeeper authorisations stamps for phase 1 of implementation. Staffing resources will also need to be identified and agreed for maintenance and further role out of Referral Management. The Executive Lead for Referral Management will be the Director of Nursing and Quality Assurance. 12. References/Further Information All Wales Policy: Making Decisions on Individual Patient Funding Requests (IPFR) Distribution This policy will be made available on the WHSSC website Review This policy will be reviewed following the completion of a revised referral management directory in