Referral Management Programme Update to the CCG Board

Referral Management Programme Update to the CCG Board Katharine Denton (Wandsworth CCG) 22 August 2014 Version 1. 22.8.2014 1

Executive Summary The Wandsworth CCG Referral Management Programme (RMP) aims to realise an overall reduction in outpatient attendances across the Borough, by reducing the number of patients referred inappropriately to secondary care. Achievements through the programme over the past year include: GP referred outpatient attendances in Wandsworth have fallen by 8.2%. Five Trusts are now live on Kinesis with over 30 different specialties and 100 consultants available to give advice. More than 3000 advice requests have been sent via Kinesis, with 50% of these resulting in a saved referral. Net Kinesis savings to date total 278,105. 100% of GPs attending referral management education sessions have reported that what they have learnt will help them make better referral decisions in future. Participation of GP practices in peer review and education has increased. 88% of practices participating in an Outpatient Incentive Scheme pilot reported a drop in their baseline number of referrals. As a result, the Outpatient Incentive Scheme has now been rolled out to all practices in the Borough. Over the next year, the RMP Team will continue to expand and develop key elements of the programme, with the aim of ensuring it becomes embedded into the day to day working of all practices, so that patients can continue to be treated in the right place, at the right time and by the most appropriate professional for their needs. Version 1. 22.8.2014 2

1. Introduction 1.1. Background The Wandsworth CCG Referral Management Programme is a suite of innovative initiatives which support Wandsworth GPs in making high quality referrals and improve the patient pathway and experience. As such, the programme aims to realise an overall reduction in outpatient attendances across the Borough, by reducing the number of patients referred inappropriately to secondary care. The programme has been created using input from GPs, patients and clinical providers and includes the following work-streams: - Accurate referral information: using EMIS data sourced from the practices - Shared learning and best practice: A programme of peer review and education - Streamlined referral processes and pathways: Supporting clinical decision making - Improved communication between clinicians: using the Kinesis on-line advice tool Unlike referral management centres across the country, the Wandsworth CCG programme seeks to empower and educate GPs to make the right referral decisions in collaboration with their patients. The programme has been running since June 2012. 1.2. Purpose A paper outlining progress and planned development of the Referral Management Programme (RMP) was presented to the Wandsworth Clinical Commissioning Group Board in July 2013. This paper provides an update for Board members on overall performance and key programme initiatives. 2. Overall Performance One of the fundamental aims of the RMP at its inception was to improve the quality of outpatient referrals and subsequently reduce the number of inappropriate outpatient attendances taking place across the Borough. Recent analysis of SUS data from the last 3 years shows a fall in outpatient attendances since shortly after the RMP launched in June 2012 (see Figure 1), whilst NHS England data from April 2014 shows that GP referred outpatient attendances are down by 8.2%, when compared with April 2013 (see Figure 2). This reduction in attendances is taking place in spite of the growing and ageing population of Wandsworth (JSNA 2012/13), indicating that the programme is successfully supporting GPs to manage patients in the community where appropriate. Version 1. 22.8.2014 3

Figure 1. Illustrates the trend in outpatient attendances over the past 18 months. The graph shows a fall in overall numbers since October 2012, shortly after the RMP launched. Physiotherapy and Podiatry have been removed from the data as these services have recently come off a block contract in Wandsworth. Data includes all providers. 3. Key Initiatives The RMP consists of four core work-streams, managed by a team of two full time CCG staff responsible for administrating all aspects of the programme. In addition the RMP Team seeks to continuously develop, expand and improve the programme in response to feedback from GPs and patients across the Borough and in-line with national best practice. The following provides an update on each of the work-streams over the past year. 3.1. Peer Review Peer reviews are GP-led and take place on a quarterly basis at each GP practice. All GPs from the practice attend, each bringing referrals for discussion within the group so that learning and best practice can be shared. Practices are given three months to complete each peer review; they then provide feedback to the CCG s RMP Team. Over the past year, peer reviews have focussed on Ophthalmology, ENT, Neurology and Gynaecology, all of which feature on our top 10 most referred specialty list. Participation from practices has improved over the period, with 30 taking part in the most recent activity. Version 1. 22.8.2014 4

Figure 2. Shows the change in GP referred outpatient attendances across CCGs in South West London between April 2013 and April 2014. Wandsworth CCG has seen the biggest reduction in attendances over the period, whilst Kingston and Richmond CCGs have experienced a rise. Version 1. 22.8.2014 5

We believe that this increase in participation is primarily due to direct targeting of nonparticipating practices by the RMP Team. Key learning points from each of the peer reviews are written up into a report and shared across all practices in the Borough. In the past year we have also introduced a you said, we did section to the report, which enables us to demonstrate how we have acted on the feedback provided by the practices. 3.2. Educational Sessions The RMP peer review process is supported by a programme of educational seminars which reflect the peer review themes. Secondary care consultants from St George s Hospital facilitate the events, which focus on the management of commonly referred conditions in primary care. Over the past year, attendance and feedback at these events has been excellent, with 100% of GPs reporting that what they have learnt will help them to make better referral decisions in the future. Across a total of eight seminars held, an average of 41 out of 43 practices have sent a GP representative; who is then expected to feedback learning to other clinicians within their practice. Due to the popularity of these sessions and the clear educational benefits, the CCG Workforce Development Leads and the RMP Team have recently agreed to throw them open to all referring clinicians rather than just the RMP lead GP for each practice. We hope that this will further improve the quality of referrals by embedding best practice and learning amongst new salaried and locum GPs across the Borough. 3.3. Online Advice Service Kinesis is a secure web-based tool through which GPs can ask for expert advice regarding referrals with a 24 hour turnaround. Originally started in November 2012 as a pilot at St Georges Hospital, over the last year we have worked hard to expand the service to another four Trusts (Chelsea and Westminster, Kingston, Guys and St Thomas and South West London and St Georges Mental Health) and now have over 30 specialties online, with 106 Consultants available to provide advice. As of 22 nd August 2014 there have been 3032 advice requests sent to consultants via Kinesis with just over 50% of these resulting in a saved referral. This means that approximately 1600 patients have avoided an unnecessary outpatient appointment since the service began. It also represents a significant saving to the CCG as each first outpatient attendance costs approximately 200 (see Figure 3). Version 1. 22.8.2014 6

Consultants continue to offer timely advice with 75% of responses meeting the 24 hour turnaround, however over the past year; the RMP Team have worked with Kinesis software providers Cloud2 Ltd, to develop and implement a number of service enhancements, including a 24 hour automatic alert system for consultants, which we hope will further improve turnaround time. Figure 3. Shows Kinesis activity over the past year against recorded savings. Although savings to date remain around the 50% mark, the RMP Team have been working closely with individual GPs and practices to ensure that messages are completed and that saved referrals can be documented. According to recent feedback from GPs and Consultants, additional benefits of Kinesis include: Ability to manage patient expectations through rapid access to specialist advice Improved relationship between primary and secondary care Long term educational benefits and change in practice Improved quality of referrals i.e. diagnostic tests completed in advance 3.4. Monthly Reporting (See Appendix A Kinesis case studies and quotes from users) To support practices in managing their own referrals, practices receive a monthly STORM (Strategic Total Referral Management) report, which displays referral activity based on EMIS read code information. The report is searchable via specific referral data (such as GP, specialty and acute provider), enabling practices and GPs to compare themselves with one another. GPs can drill down into the report to review individual referrals, whilst the dashboard also provides valuable aggregate data and targeting information for the RMP Team and the Wandsworth Locality Commissioning Groups. Over the past year there have been issues with updating the report due to changes in information governance legislation. These have now been resolved and the reports are actively being used by practices to monitor trends and improve the quality of their EMIS coding. Version 1. 22.8.2014 7

The RMP Team are currently working with the software provider to launch a new version of STORM which will be more user-friendly and enable practices to compare themselves with one another based on standardised list sizes and demographic trends. 4. Ongoing Development As part of an ongoing feedback process, the RMP Team is continuously looking at ways to improve on the existing work-streams and find innovative ways to support practices in improving the quality of referrals. The following describes two new initiatives that will be rolling out in 2014/15. 4.1. Decision Support Software A procurement process is currently underway for a piece of clinical decision support software which will enable GPs to access all referral forms, templates, local and national guidelines in one central location. The tool will be interactive, sitting within the existing clinical system to enable GPs to make better informed referral decisions. We anticipate beginning implementation of the software in September 2014 and expected outcomes include improved adherence to locally developed pathways and increasingly standardised referral practices. 4.2. Outpatient Incentive Scheme In October 2013, the RMP Team launched a pilot outpatient incentive scheme which aimed to support practices in developing innovative ways to manage their referrals and to promote collaboration in offering quality care to patients. Results from the initial six month pilot were very positive with 88% of the participating practices reporting a drop in their baseline number of referrals. In addition, GPs found the scheme beneficial in improving their knowledge of local pathways, utilising in-house expertise more effectively and collaborating with other practices. The scheme has now been rolled out to all practices in Wandsworth and we will be monitoring its progress throughout the remainder of the year. 5. Summary The Wandsworth Referral Management Programme is now entering its third year of operation and data analysis shows that it is successfully impacting outpatient attendance numbers across the Borough. Over the next year, the RMP Team will continue to expand and develop key elements of the programme, with the aim of ensuring it becomes embedded into the day to day working of all Version 1. 22.8.2014 8

practices, so that patients can continue to be treated in the right place, at the right time and by the most appropriate professional for their needs. The CCG Board is asked to note the content of this report. Version 1. 22.8.2014 9