GOVERNING BODY MEETING in Public 27 September 2017 Paper Title Report Author Neil Evans Turnaround Director Referral Management s Contributors John Griffiths Date report submitted 20 September 2017 Dean Grice Interim Project Manager Primary Care Commissioning Manager Purpose of paper As part of the CCG QIPP plan the options to reduce expenditure on secondary care activity has been undertaken. In support of this the use of Referral Management s (RMS) has been undertaken and a business case developed to maximise the associated savings which can be realised. Reason for consideration by Governing Body In order for the CCG to meet our agreed financial plan delivery of a significant QIPP is required. Failure to deliver the values identified in our QIPP programme will prevent the CCG from achieving the savings needed. Outcome Approve Ratify Decide Endorse For Required: information Recommendation The Governing Body is asked to Approve recurrent investment of an estimated: 61k in Referral Management s software 115k in clinical capacity to deliver clinical triage 157k in booking services 200k in clinical treatment costs through expansion of community based alternatives Non recurrent implementation costs of 57k ( 42k Project Management and 15k IT set up costs The Governing Body is asked to note for information that: 111k of the first year costs would be offset by finance secured from NHS England through the ETTF (Estates and Technology Transformation Fund). That the projected savings are 1.64m ( 1.3m net). This is based on a prudent estimate of 8% reduction in activity with the estimate based on working closely with a number of peer CCGs who have implemented similar solutions. Benefits / value to our population / communities Consistent high quality care across primary and community based settings using nationally evidenced best practice and clinical education and support. Reduction in unnecessary hospital attendances and treatment. Protects other vital local services through redeployment of resources
Key Implications of this report please indicate Strategic Consultation & Engagement Financial Resources (other than finance) Procurement Decommissioning Equality Quality & Patient Experience Safeguarding Governance & Assurance Legal / Regulatory Staff / Workforce Other please state Governing Body Assurance Framework Risk Mitigation: GBAF 280 2017/18 QIPP Programme (Financial Recovery) GBAF 282-2017/18 Financial Deficit Report/Paper Reviewed by (Committee/Team/Director) Neil Evans Turnaround Director Page 2 of 15
Business case for investment in Referral Management s 1. Executive Summary 1.1. The CCG needs to find significant savings and maximising the benefits of clinical triage of non-urgent referrals to secondary care has been locally and nationally determined as an effective way of doing this. 1.2. The use of a Referral Management (RMS) has been identified as the most effective way to ensure a consistent and effective approach. Based on a thorough review of evidence and the experience of other CCGs a three-step process comprising of referral software, clinical triage and an onward administrative booking service has been identified as the optimal solution to maximise financial savings whilst maintaining a positive patient experience and robust clinical governance. 1.3. Whilst costs of 533k (recurrent) and 57k non-recurrently would be incurred to implement this approach across six high volume/impact clinical specialties the net savings in the first full year of implementation have been estimated to be 1.31m. 1.4. The CCG has secured 111k non-recurrent funding from the NHS England ETTF (Estates and Technology Transformation Fund) to support the initial costs of implementing an RMS. 1.5. The options appraisal has been developed through close working with other CCGs, who have realised savings from implementing these approaches and through strong engagement with local GPs and clinical leads. 1.6. The approach advocated offers real benefits to patients through consistent application of best clinical practice achieved through support and education of referring clinicians and directing patients to the right services at the right time. 2. Recommendations 2.1. The Governing Body is asked to Approve recurrent investment of an estimated: 61k in Referral Management s software; 115k in clinical capacity to deliver clinical triage; 157k in booking services; 200k in alternative community based clinical treatment services Non-recurrent implementation costs of 57k ( 42k Project Management and 15k IT set up costs. 2.2. The Governing Body is asked to note for information that: 111k of the first-year costs would be offset by finance secured from NHS England through the ETTF (Estates and Technology Transformation Fund); and That the projected savings are 1.31m ( 1.64m gross) in 2018-19 and 1.20m in 2019-20. Page 3 of 15
3. Reasons for recommendations 3.1. To ensure there is a consistent approach to secondary care referrals and to realise the financial savings identified in this document. 4. Peer Group Area / Town Area Affected 4.1 All 5. Population affected 5.1. The Eastern Cheshire population and those registered with an Eastern Cheshire GP Practice would be affected although the proposal is to initially target specific specialties. 6. Context 6.1. The CCG is committed to improving the quality and efficiency of making referrals to the right place, right time quickly and providing services closer to home. It is locally and nationally recognized that a number of patients being referred to hospital outpatients could be managed differently without having to be referred to a hospital. As a consequence, NHS England has advocated, through the Elective Care High Impact Interventions Programme the benefit of clinical triage. 6.2. From research, the use of a Referral Management (RMS) has been identified as the most effective way to maximise the consistency and success of applying this approach. In addition the CCG has secured 111k non recurrent funding from the NHS England ETTF (Estates and Technology Transformation Fund to support the initial costs of implementing an RMS. 6.3. Whilst the mean NHS Eastern Cheshire CCG GP referrals rates benchmark reasonably well with peers there remains an opportunity to reduce variation of referrals between GP practices through consistent clinical referral protocols. In turn this helps to improve the patient experience and outcomes as well as helping to deliver some of the CCG s QIPP plan, thereby achieving financial balance and stability. 6.4. A RMS improves and streamlines communication amongst GP s, specialists, and any other health providers involved in a patient's care with a view of providing the right care at the right place quickly and efficiently. Page 4 of 15
6.5. A RMS comprises of the following elements: Guidance on referral pathways. A software platform that manages the referrals electronically. Clinical review and advise to support GP s in developing individual referral pathways for patients to ensure quality of referral and decision making process in order to avoid duplication or inappropriate referrals. A Screening and Booking Process, by offering choice advice and support to the patient for booking specialty appointments from a centralised booking system. 6.6 An overview of a fully integrated RMS process is as follows. 6.7 We have also explored the use of a Guidance Tool such as Map of Medicine (MoM). The business case however has determined that the projected 70k cost ( 30k recurrent license costs) is not a priority compared to the other components. Alternative approaches will be taken to document local pathways. 6.8 A summary of the key benefits and potential risks of an RMS have been summarised as: Element of RMS Benefits Potential Risks RMS Platform Reduces inappropriate Might increase costs. referrals. Might demotivate GP s. Directs referrals to Might demotivate providers. most appropriate clinical setting. Might mis direct referrals in the absence of timely and Improves quality of accurate information. referrals. Might act as a barrier Can help to fast track care. between GP s and Specialist Consultants. Provides evidence for commissioning Software issues / risks of failure. intentions. Providers going bankrupt. Provides real time information. Risk of breeches of patient confidentiality. Page 5 of 15
Element of RMS Benefits Potential Risks Reduces variation. Can provide significant savings in overall planned care. Helps to direct care into the Community, care closer to home for the patient. Supports providers to focus on more specialist care and ease capacity issues. Provides providers with better information & quality of information. As the NHS changes through STP, RMS can act as an enabler for change in referrals thereby creating a simple and effective way of directing referrals. Help to repatriate referrals to clinical centres closer to home. Clinical Triage Directs referrals to most appropriate clinical setting. Educates GP s. Improves quality of referrals. Provides a more consistent process of referrals and equity. Is a tool to help to identify PLCV referrals which can then be returned back to the referring GP. Improves quality of referral letters. Might increase overall costs. Might misdirect referrals in the absence of full clinical information or misinterpretation. Provides another barrier and holds up treatment. Might delay access to specialist. Risk of breeches of patient confidentiality. Remoteness and consequently knowledge of triager. Page 6 of 15
Element of RMS Benefits Potential Risks Can change referral behavior. Upgrades non-urgent to urgent care thereby providing quick and effective care. Supports the development of clinical pathways. Provides an opportunity for GP s and specialists to engage in becoming a Triager. Empowers GP s. Helps to direct care into the community, care closer to home for the patient or back to primary care and selfcare. Supports providers to focus on more specialist care and ease capacity issues. Booking Releases GP s from the Booking process enabling them and their staff to focus on more clinical care. Speeds up the booking process. Improves consistency and equity across the system. Offers Choice to the patient with supporting information. Provides an audit trail and confirmation of bookings and any additional information if appropriate. A source of information and support. Might overall increase costs. Might lengthen booking process if not managed effectively. Might misdirect referrals in the absence of accurate and timely information. Risk of breeches of patient confidentiality. Remoteness and consequently understanding and knowledge of Booking Centre. Page 7 of 15
6.9 NHS Eastern Cheshire CCG has a lower than average referral rate, when compared with other CCGs locally. This is demonstrated within the table below, but this graph also shows that there are CCGs who have lower rates of referral nationally and within the case studies we have undertaken we identified NHS Vale of York CCG who have seen significant reductions. Based on this evidence review it has been assessed that an 8% reduction in referrals is a prudent estimate of the likely reductions in Eastern Cheshire. 6.10 Whilst there are differences in variation, it is important to note that the demand for health services is likely to significantly increase in the next five years due to: Increasing population of around 2% by 2020 to 208,100 and by 14% to 232,000 by 2035. Change in demographics of the population in that the residents of the CCG are more elderly. This age structure of the population is forecast to change significantly with a reduction of young people and the working age population, with a 42% increase in people over 65 years and a 92% increase in those over 85 years old by 2035. (Office for National Statistics, 2010). One in five of the population will be over 65 compared to the national average of 16% and will become one in four by 2021. We have the fastest growing over 65 and over 85 years populations in the North West. These demographic changes will significantly affect the demand for health services including planned care and this is in the backdrop of limited clinical and financial resources available to the NHS. There is a national shortage of both clinical and nursing staff, particularly in areas such as Dermatology. Peoples knowledge together with the availability of information increases demand and expectations of health issues. The likelihood of people living longer and many will be wanting to be active longer. 6.11 The CCG s main local acute provider, East Cheshire NHS Trust has a number of 18 week Referral to Treatment (RTT) challenges in which the CCG, wishes to support and RMS is an enabler to change referrals patterns. Page 8 of 15
6.12 The CCG makes around 36,000 referrals to all providers and the biggest referring specialties detailed in the table below. 6.13 The summary of inpatient care at the CCG is detailed is detailed below. 6.14 We have consulted a number of CCGs nationally, who have successfully implemented an RMS, and all have been successful at deflecting activity out of hospital, including to a more appropriate setting including community care. 6.15 After a review of this information, consultation with local Clinicians, consideration of the local RTT pressures, the proposed scope of our initial phase of triage following care pathways: Page 9 of 15
Musculoskeletal Services (Orthopaedics) Cardiology Paediatrics Gastroenterology General Surgery Ophthalmology 6.16 Following a thorough review of different implementation options we assessed the following options to consider. Option 1 Do Nothing Option 2 RMS Platform Option 3 Triage Option 4 Booking 1a Status Quo 2a No Platform 3a No Triage 4a No Booking 2b Provider A Platform 3b In- House Triage 4b In-House Booking 2c Provider B Platform 3c Hospital Triage 4c Hospital Trust Booking 3d Provider A Triage 4d Provider A Booking 3e Provider C Triage 4e Provider E Booking 3f Provider D Triage 4f Provider D Booking Page 10 of 15
6.17 After detailed evaluation of each of these options our conclusions are as follows. RMS Platform OPTION Potential Suppliers Notes Evaluation 1a Do Nothing No Investment. The CCG needs to improve the quality of referrals for patients so that they receive the right care at the right time quickly and effectively, closer to home. RMS is an enabler and a tool for this to happen. There is also a lost opportunity to develop some QIPP savings. There may be scope for use of E Referral in the future but timescales are unclear. AMBER 2a No Platform No investment required. Opportunity to gain live performance data and tracking individual patient pathways will be lost. 2b Provider A Platform No quote received. Advice & Guidance only. Small infrastructure. 2c Provider B Platform Quote received - 61,192. RMS. Well established in a number of CCG s with positive references. Triage 3a No Triage No investment required. No advice and guidance to GPs and PLCV will continue not to be screened. Variation likely to continue. 3b In-House or GP Consortium Difficulty in recruiting staff. Not easily implemented. Need to establish governance and management arrangements. Distraction from core service. 3c Hospital The Trust is not in a position to provide a fully comprehensive managed triage service, but maybe willing to provide individual triagers to another provider. 3d 3e Provider A Triage Provider C Triage No quote received. Advice & Guidance only. Small infrastructure 20k - 276k. Not for Profit Co. Well established in a number of CCG s with positive references. 3f Provider D Triage Not progressing due to capacity and local presence Booking 4a No Booking No investment required. No initial screening, inconsistent referrals will continue and GPs will continue to book patients. 4b In-House or GP Consortium Difficulty in recruiting staff. Not easily implemented. Need to establish governance and management arrangements. Distraction from core service. 4c Hospital The Trust is not in a position to provide a fully comprehensive managed booking service for all CCG referrals. 4d 4e 4f Provider A Booking Provider E Booking Provider F Booking Provider A do not provide this service 187k. Part of the NHS (CSU). Well established in a number of CCG s with positive references. No procurement issues. Not progressing due to capacity and lack of local presence. GREEN AMBER GREEN GREEN Page 11 of 15
6.18 We also reviewed the NHS e-referral system (ERS) which is being developed to offer advice and guidance, and we understand this may be available as soon as February 2017. However, at this stage, this is currently unavailable and consequently have not seen or reviewed this product and it has not been tested. As this option is uncertain and unavailable, we are ruling out this option, but the CCG may wish to visit this in the future if/when it has been proven to be effective. We therefore suggest that should the CCG wish to progress an RMS then it does so on a one year pilot so it does not enter into any long-term commitments and has a chance to evaluate the system and consider alternatives at that time. Whilst the planned national approach for ERS: GP usage of ERS is not consistent so to exploit this development, noting it would need GP and not reception usage. The process does not require a standard approach/content in a referral so may lack relevant information for accurate advice and guidance. It is not easy to monitor advice and guidance (as can be from any provider selected) so may be inconsistent and not in line with local pathways/standards. For the reason above governance is not easy to apply. 7. Finance 7.1 The following table sets out the financial implications of this business case: RMS Implementation - Financial Summary with Booking Service Item Year 0 (set-up) Year 1 Year 2 Total Activity-driven Increase/(Decrease) in Cost - 1,842,559-1,732,643-3,575,202 Cost of RMS Software 61,193 61,193 122,386 Booking (21,000 Referrals) 157,080 157,080 314,160 Triage (21,000 Referrals) 115,071 113,381 228,452 Estimated Costs for additional community alternatives 200,000 200,000 400,000 IT Set-up 15,280 0 15,280 Project Support 41,500 0 41,500 NHS England Contribution - 111,000 0-111,000 Totals - 54,220-1,309,215-1,200,989-2,564,424 7.2 Should the pilot be shown to be successful and realise the projected benefits further specialties can be added although the costs of booking and clinical triage would proportionately increase. 7.3 We have included a proposed reserve of 200k to enable the implementation of any Community Clinics. Separate Business Cases would need to be developed to assess their feasibility, but Community Clinics do provide the following benefits: Provides additional capacity into the health community. Provides care closer to home for the patient which is often more convenient and cost effective for patients (reduces public transport / car parking to/from at hospital) Provides a more appropriate clinical setting for patients. Improves patient experience. Improves patient choice and often wait times. Enables more specialist hospital clinicians to focus on more specialised / urgent care. Page 12 of 15
Supports hospitals with their RTT. Engages local GP s and clinicians with the provision of care. 8. Quality and Patient Experience 8.1 We have engaged with a number of CCG s where we have seen evidence of positive feedback from service users and clinicians. Service Users main direct contact is with a Booking Service and this element of the service has shown very positive feedback from service users. 8.2 The triage of non-urgent referrals can also highlight where a patient may require more urgent assessment e.g. upgrade onto a cancer 2 week wait pathway. 8.3 The principle of referral software/clinical triage is both to support the application of best practice care through standardised pathways and education as well as support patients get to the right service or treatment in a timely manner. 9. Consultation and Engagement 9.1 As part of the preparation of this Business Case, we consulted with both our Clinical Leads and the August GP Locality Meeting and they provided feedback which has led to the recommendations in this paper. 9.2 In development and assessment of options we have visited a number of sites including a nominated GP from the CCG to look at their approaches. 9.3 If the governing body supports progression of this development we would seek to work with members of the public on the detailed implementation plans. This has been communicated at the September Health Voice meeting. 10. Equality 10.1 We have completed the QIA, PIA and EIA returns and they are available on request. 11. Legal 11.1 We are recommending to undertake a 12 month pilot in which there will be an evaluation undertaken at the end of this pilot. On this basis, it is proposed that we will procure under local arrangements. As part of the evaluation the longer-term procurement/provision options will be further reviewed. Page 13 of 15
12. Implementation Plan 12.1 We have undertaken a high-level Implementation Plan which is available on request. We estimate that it will take around 6 months to plan for implementation and a further 2 months to roll out across all practices within the CCG. We would aim to go live in April 2018 and be rolled out by June. We would envisage a programme would go through a ten stage process, as outlined below. 12.2 To govern this process, we would establish a Steering Group and an Implementation Group and have defined its membership and Terms of Reference which are available on request. 12.3 In order to implement this, we would need senior commissioning support, administrative and PMO support and would need clinical representation. 13. Access to further information 13.1 For further information relating to this report contact: Name Neil Evans Designation Turnaround Director Date 18/09/17 Telephone 01625 663378 Email neilevans@nhs.net 13.2 We would like to acknowledge and thank a considerable amount of people in helping us to construct this Business Case and this includes officers and GP s from other CCG s, GP s from this CCG and potential suppliers. Page 14 of 15
Governance CCG 5 Year Strategic Plan programme of work this report is linked to Caring Together Quality Improvement Mental Health & Alcohol Other CCG 5 Year Strategic Plan ambitions addressed by this report Increase the number of our citizens having a positive experience of care Increase the proportion of older people living independently at home and who feel Reduce the inequalities in health and social care across Eastern Cheshire Ensure our citizens access care to the highest standard and are protected from avoidable harm Ensure that all those living in Eastern Cheshire should be supported by new, better integrated community services supported to manage their condition Improve the health-related quality of life of our citizens with one or more long term conditions, including mental health conditions Secure additional years of life for the citizens of Eastern Cheshire with treatable mental and physical health conditions Key Implications of this report please indicate Strategic Consultation & Engagement Finance Equality Quality & Patient Experience Legal Staff / Workforce CCG Values supported by this report please indicate Valuing People Innovation Working Together Quality Investing Responsibly NHS Constitution Values supported by this report please indicate Working together for patients Compassion Respect and dignity Improving lives Commitment to quality of care Everyone counts Page 15 of 15