Referral Management:

Candace Imison, Director of Policy

What does the evidence tell us

A growing imperative to manage referrals

What’s the evidence?

Ten fold variation in rate of GP referral

Source: Imison & Naylor, 2010

Source: Imison & Naylor, 2010

A variety of approaches to GP referral

management

Source: Imison & Naylor, 2010

Management – tackles a variety of factors

Source: Imison & Naylor, 2010

Questionable Value for Money

• Referral management centres carry a large overhead cost that is likely to outweigh savings from any reductions in referrals.

• BMJ FOI request to CCGs - only 10/72 CCGs able to demonstrate any savings from referral management schemes.

• Any strategy to reduce over-referral may also expose under-referral.

• Reductions in referrals from one source can be negated by rises from other sources, so any demand management strategy needs to consider all referral routes and not just target one.

Source: Imison & Naylor, 2010

Source: Imison & Naylor, 2010

Impact of secondary care referral assessment

service

Wolverhampton Gastroenterology Services

• Secondary care clinicians (gastroenterology) assessed referrals for appropriateness

• Used electronic proforma

• Systematised pathways of care for most common patients

Impact

• 32% patients discharged to primary care with letter of advice

• 60% patients offered outpatient appoints – 23% had bloods arranged in advance

• 5.2% directed to other specialists

• DNA rates fell – 14% -> 8.5%

Source: Pelitari et al, 2017 GUT - BMJ

http://gut.bmj.com/content/66/Suppl_2/A8.1

Any referral management system requires strong

governance

• Strong governance needed to manage clinic risks and potential conflicts of interest

Clinical risks

• Ensure appropriate referrals are not being diverted => late or missed diagnoses and treatment.

Conflict of Interests

• General Practice

• Referral to alternative GP led or delivered services in which GP has financial interest.

• Secondary Care

• Holding on inappropriately to activity for which the provider will be paid.

CONNECTING CARE FOR CHILDREN

DR BOB KLABER

Imperial College Healthcare NHS Trust

@bobklaber @CC4CLondon

Transforming outpatients services

CC4C Logic Model - Adapted August 2017 from CC4C/CLAHRC Early Years 2014 A:E diagramMando.Watson@nhs.net M.Blair@imperial.ac.uk bob.klaber@nhs.net

THE LOGIC BEHIND OUR MODEL OF CARE:

GLOBAL AIMS

PRIMARY DRIVERS

Some examples of SECONDARY

DRIVERSIncrease shared knowledge about services

Focus on connections and relationships

Increase parents and professionals capability in

child health issues

Include whole population to drive prevention &

improve equity

Focus on outcomes that really matter to patients

Better quality of care

Better population health

Reduced per capita cost

Better staff experience

Inter-professional support = OPEN ACCESS

Professional education packages = SPECIALIST

OUTREACH

Patient support & education = PATIENT & PUBLIC ENGAGEMENT

• 3-5 GP practices within existing locality

• ~20,000 practice population, (~4,000 children)

CHILD HEALTH GP HUB

• 3 core elements• Centred in primary care• Built around monthly

MDT and clinic

DEMONSTRATING VALUE AND BENEFITS

Improved patient

experience of care

Reduced per-capita cost

Improved staff

experience & learning

Improved population

health

Reference: Montgomery-Taylor, S., Watson, M., & Klaber, R. (2016). Child health general

practice hubs: a service evaluation. Archives of disease in childhood, 101(4), 333-337.

USE OF HOSPITAL SERVICES

NEW CARE MODELS IN CHILDREN –DESIGN PRINCIPLES

1. Focus on connections and relationships; NHS services can be minimally

changed, while their capability and capacity are maximised

2. Harness existing strengths: put GP practices at the heart of new care models

- specialist services are drawn out of the hospital to provide support & to help

connect services across all of health, social care and education

3. Include the whole population, (using segmentation to create bundles of care)

to drive prevention and improve equity

4. Health seeking behaviours improve through peer-to-peer support

5. New approaches to care to be co-designed with children, young people,

parents, carers and communities

6. Focus on outcomes that really matter to patients

7. Use education and development, for the whole multi-professional team, as a

key way to build relationships and finding new ways to work together

Transforming Outpatients:

Was Not Brought

(not DNAs)

Jenny Handforth

November 2017

Was not Brought rather then DNA

• ‘WAS NOT BROUGHT’

• CHANGING THE MIND-SET OF:

• the admin teams

• the clinicians

• JUNIOR DOCTOR INDUCTION

• ADMIN INDUCTION

• YOU TUBE CLIP; RETHINKING ‘DID NOT ATTEND’-

NOTTINGHAM SAFEGUARDING TEAM

27

What did we do?

PDSA

• Designated OPD transformation team-clinicians/Admin/AHP

• Review of patient journey

• Identification of red flag areas

• Patient experience

• Data analysis of trends/hot spots

• Brainstorming of ideas for next steps

• Lean modelling of pathways

• Allocation of projects

• Analysis of data again

• Revision and further tweaking

28

Key aspects

• Admin

• Communication

• Letters

• Dr Dr

• Telephone reminders

• Clarity re Contact number for families

• SARD use

• Outcomes/PIMS timeliness/accuracy

• Lean work-shadowing admin team

• Clinical

• SARD-universal for all leave-no exceptions

• Trust cancellation policy enforced

• Red flag escalation policy

• Trend analysis

• Lean work around clinic cancellations

• Risk register

• Outcomes

• Multiple DNAs

• Waiting list back log impact awareness

• Clinician scorecards

29

Ongoing

Monthly OPD Transformation team meetings

• Trends and Patterns

• RCA and Insights

• Actions set and progress to date reviewed

Monthly Report

• Historic backlog to SM and HoS

Weekly Reports

• Completion data to SM and HoS

• Error report for reception team to action

• Multiple DNAs/cancellations from previous week sent to clinicians for active plan

Weekly

• Admin/nursing/OPD staff engagement with clinicians-re outcomes and DNAs

• Benchmarking against other clinical areas

Evelina Access policy in draft

WNB/DNA Trends

WNB/DNA Rates

remain low at around

8-9%

Scorecard

Children's Medical Services

Scorecard

Children's Surgical Services

What else is going well?

• % missing notes remains

consistently low below 5%

• Clinic room utilisation consistently

high since new consultants

commenced posts in Q4 16/17.

• Reduction in number of short

notice avoidable cancellations

following stricter approach from

DMTs, red flag system, letter

from OP clinical lead.

• 96% parental FFT

recommendation

What is going less well?

No improvement in:

• reducing follow up backlog

• reducing delay to start of appt

• increasing outcome

completion

Any Questions?

Value based design of Geriatric Care

Tom Downes

Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals

21st November 2017

Gastroenterology ServiceRyhov Hospital, Jönköping, Sweden

The Big Room (Obeya)

PDSA cycle 1One patient, one day

• Current system takes ~3 months from seeing GP to receiving a management plan

• Prediction: shorten this to under 8 hours in a single visit

• Completed in 3hrs 10mins

• Patient and daughter left with written management plan in hand

Sheffield Frailty Assessment UnitOpens 4th December 2017

SheffieldFrailty AssessmentUnit

www.sheffieldmca.org.uk/flow

FCA Sheffield

FCA Bath

Flow Coaching Academy Programme

FCA Imperial

FCA NorthumbriaFCA Northern Ireland

FCA Birmingham

FCA Exeter

Transforming outpatient ServicesBibhas Roy

Consultant Orthopaedic Surgeon (Shoulder & Elbow)

Central Manchester Foundation Trust

Health Service Journal Top Innovator 2013

MIMIT, Manchester Interdisciplinary Biocentre

www.proms2.org

OUTPATIENT CLINICS; THE NUMBERS (DEC 2016)

o 113.3 Million outpatient appointments in

2015-16

o 89.4 (78.9%) Million were attended

• first attendances 31%(27.3 million out of

89.4 million)

o Hence 69% of outpatients appointments are

follow-ups

o Patients aged 65 to 69 had the highest

number of attendances

http://content.digital.nhs.uk/catalogue/PUB22596/hosp-epis-stat-outp-summ-repo-2015-16-rep.pdf

SPECIALTIES

VIRTUAL CLINIC

• Virtual clinic is a contact between the clinical team and the patient to plan

clinical care without direct face-to-face meeting.

• However, there is a lack of standard definition in the context of virtual clinics in

their descriptions, technologies used, services offered etc.

• The term has been used to indicate very different set of services

ATTRIBUTES OF VIRTUAL CARE DELIVERY

• What is it?

• Hi-Tech

• Tele-something

• Asynchronous

• Outsourced

• Anonymous

VIRTUAL CARE DELIVERY

Real Patient Virtual Patient

Real Provider Traditional clinicsPatient accesses information before

exercising choice

Virtual ProviderRemote monitoring from the clinical

service teamSupport groups, patients forums etc

Proc AMIA Symp. 2001 : 244–248. PMCID: PMC2243512

Virtual healthcare delivery: defined, modelled, and predictive barriers to implementation identified.

V M Harrop, MIT, USA.

PATIENT-REPORTED OUTCOME MEASURES: AN ON-LINE SYSTEM EMPOWERING PATIENT CHOICE

• Virtual clinic F/U - planned surgery

• ASAD

• Pre and post treatment data can be gathered for audit,

research, service improvement

• The focus is on reducing unnecessary follow up

appointments

• Uses PROMs to guide F/U 55

E-MAIL TO PATIENT

REGULATORY FRAMEWORK

• Data protection Act – 1998 (DPD -1995)

• General Data Protection Regulation - EU

• January 2012, the European Commission proposed a

comprehensive reform of data protection rules in the EU

• 14th April 2016 – adopted by European parliament

• 24th May 2016 enter into force

• 6th May 2018 applies as law to all of EU

http://eur-lex.europa.eu/legalcontent/EN/TXT/PDF/?uri=CELEX:32016R0679&from=BG

Consent also has to be a positive indication of

agreement to personal data being processed – it cannot

be inferred from silence, pre-ticked boxes or inactivity

VIRTUAL CLINICS AND DATA SECURITY

• New patient – clinician relationship

• Define roles and responsibilities

• Contracts and Consents (patients

are not employees, are

consumers)

• Patient information documents

and informed consents

• Security has to extend to patients

Developing a service based on clinical risk for patients in

glaucomaFiona Spencer

Manchester Royal Eye Hospital

Managing Glaucoma in Manchester : Capacity vs Demand • Chronic condition, treatment, not cure

• Increasing aging population

• Increased case finding from optometry

• Success in keeping patients sighted increases workload

• High risk/post-op patients means frequent visits

• Less medical staff in SAS posts

• Manchester 13,500 glaucoma patients, 3 consultants in 2015

2010

4.9 million

>75 years

1.4 million

>85 year

2035

8.9 million

>75 years

3.5 million

>85 years

Engaging the wider workforce• Developed team with visual scientist, lead optometrist

• Engaged with Local Optical Committee & Commissioners

• Trained optometrists in community in referral refinement: GERS

• Trained optometrists in HES in glaucoma assessment & management: OLGA

• Trained nurse practitioners in patient education: ‘Get a Grip on Glaucoma’

• Trained ophthalmic science practitioners : Virtual Clinic

• Ensured new consultants were engaged and responsible for area of development

• Developed post CCT fellowships: Consultant complex clinics

Service based on clinical risk

• Referral refinement to triage new patients; reduce 40% false positives

• New Optometric Led Glaucoma Assessment (OLGA) Clinics

• New patients invited to Education: ‘Get a Grip on Glaucoma’

• GEC Virtual Clinics for lowest risk patients (OHT/suspect)

• OLGA follow up clinics for moderate risk: also in community

• Consultant clinics for complex/high risk and surgical patients

• Interim GEC Virtual clinics for backlog/long waiters

Lessons Learned• We have developed a ‘consultant light’ and ‘resource light’ service

• Developing the team was key: training and accreditation of roles

• Engaging with stakeholders/commissioners vital to share vision

• Audits/publications/patient satisfaction surveys to demonstrate outcomes

• Ensuring new consultants have ownership strengthened service

• Takes time to develop the service!

Delivering a digital appointment service

Guy’s and St Thomas’ and DrDoctor

Emma McLachlanProgramme Director, Digital Patient Journey

What we set out to achieve

Provide a quality digital service for patients to enable appointment booking and management with additional content (location & preparation information) to support each appointment

Patient

experienceA&C timeDNAs

The majority of our outpatients (and inpatients) receive timely confirmations and reminders via SMS

You have an appointment

booked: Mon 3rd July at

1.30pm at Guy’s and St

Thomas’ Trust

- Text CHANGE for

alternatives, CANCEL if

you don't want to be seen

- View more info and

manage this appointment

online by visiting

https://nhs.my/demo

- For any queries please

call 0207 188 7188

Content available via the web to help patients prepare for and locate appointments

71

You have an

appointment booked:

Mon 3rd July at 1.30pm

at Guy’s and St

Thomas’ Trust

- Text CHANGE for

alternatives, CANCEL if

you don't want to be

seen

- View more info and

manage this

appointment online by

visiting

https://nhs.my/demo

- For any queries please

call 0207 188 7188

You have an

appointment booked:

Mon 3rd July at 1.30pm

at Guy’s and St

Thomas’ Trust

- Text CHANGE for

alternatives, CANCEL if

you don't want to be

seen

- View more info and

manage this

appointment online by

visiting

https://nhs.my/demo

- For any queries please

call 0207 188 7188

You have an

appointment booked:

Mon 3rd July at 1.30pm

at Guy’s and St

Thomas’ Trust

- Text CHANGE for

alternatives, CANCEL if

you don't want to be

seen

- View more info and

manage this

appointment online by

visiting

https://nhs.my/demo

- For any queries please

call 0207 188 7188

We have achieved a 2.4% reduction in DNA rates

A&C timePatient experienceDNAs

• 91% of patients would

recommend or highly

recommend the service

(poll of ~1000 patients in

2016)

• Patients have the choice to

manage their appointments

through convenient digital

channels – reducing their

need to rely on telephone

contact

2016/17

• Contributed to a 2.4%

reduction in DNA rate within

outpatients which led to

£2,600,000 increase in

revenue through

attendance of 14,316 more

appointments

• No time saving for A&C

staff from confirmation and

reminder service

• Limited time saving on self-

serve booking as manual

process still required to

input patient details into

PAS on receipt of referral

(NB – ERS will reduce

demand by 40% for new

appointments)

• Patients mostly still calling

the hospital to change

appointments with < 3%

using SMS/web

change/cancel service

73

Lessons learned

Lessons learned

1. Implementation requires focussed resource – critical to have overarching ‘super users’ to support service managers in addition to focus from central ops to ensure standardisation and troubleshoot. Staff at SM level have a high churn and therefore central management is key

2. We are adding – not removing – process – administrative teams must now deal with parallel processes to manage appointment changes – attending to inbox as well as manning phones. This does not reduce time unless the service is fully automated

3. Limitations of existing PAS – full automation is hard to achieve with legacy systems that have no/limited logic around scheduling and appointment types e.g. linked appointments, order of appointments

4. One size doesn’t fit all – not all services have seen DNAs reduce. We need to look harder at the reasons why people DNA – motivation, fear, lack of preparation and find other ways to counteract those

5. The role of content… we want to look at trigger based communications that lead people to targeted content relevant to each patient e.g. timely reminder to ensure you’ve prepared the food you need to bring in for Paeds Allergy clinic or video from surgeon sent 36 hours prior to operation to assure patient and request they contact us with any concerns

75

Thank you.

Emma McLachlanProgramme Director, Digital Patient Journey

emma.mclachlan@gstt.nhs.uk

Inform and Transform – Outpatient

Services

Steve Ryan, EPR Programme Manager

Katie Squire, Informatics and myhealth Programme Manager

Facts and Figures

• Over 9000 staff• 1213 beds, 100 critical care beds, 32 theatres, • Circa 762,000 outpatients, 135,000 inpatients;

115,000 ED attendances

• UHBfT and Heart of England working together, potentially a single organisation serving a diverse population of 3.2 million

• Global Digital Exemplar committed to acceleration of EPR programme utilising in-house IT development and Informatics

Patients - “No decision about me without me”

• Patients want to be part of their health care

• Give patients more control, they will take more responsibility

• Patients will contribute to improving the efficiency of the service

“My Grandfather was a doctor 50 years ago and he used to run his OP clinic in the same way that I do.

A change is overdue”

James FergusonConsultant Hepatologist & UHB Clinical Lead for the MyHealth Patient

Portal

Clinicians – ‘Grandfather to Grandson, what’s changed?’

Transforming outpatients at UHB

Paper notes

Separate,

spread out

OPD

locations.

Electronic

systems for

clinicians

Centralised

OPD location.

Electronic

systems for

patients and

clinicians

Centralised

and virtual

locations.

2011 2017

2011 – removed paper notes from OPDPrescribing, clinical notes and GP letters created in PICS pulling in patient details

and medicines information into predefined templates to standardising letter

layouts.

• Patient portal developed in-house by the IT and Informatics teams

• Approached by long distance, long term care patients in 2011

• 14 Specialities in 2013 now 40 (Oct 17)

• 2400 active users in 2013 now 9088 (Oct 17)

• 17601 patients signed up (Oct17), 51.7% activation rate

• No age barrier

• Access to letters, medications, results and can contribute to record

UHB MyHealth Patient Portal

Patient feedback• 92% of patients stated they think myhealth has been beneficial in improving their

involvement in the healthcare they receive.

• 24% of respondents have displayed or reviewed their myhealth record during an appointment.

• The majority of respondents (94%) use myhealth for less than 1 hour, and for a few times a month (58%).

• The 3 sections accessed the most are the calendar (22%), letters (29%) and results (30%).

• 56% of respondents informed us that myhealth has saved them from telephoning the hospital and 12% that it had saved them from making an appointment.

• In addition 24% stated myhealth had prompted a call to the hospital and 8% stated that myhealth had prompted them to make a hospital appointment.

myVirtualClinic

• Accessed through myhealth@QEHB

• Allow follow-up patients to undertake a video consultation with their clinician from the comfort of their own homes

• Commissioners have agreed a face to face tariff for the pilot only

• Benefits include – Reduced patient travel times

– Reduced expenses for patients

– Patients can take less time off work for appointments

– Improved record of consultation

– Patient involved in creating their health record and plan

– Free up more clinic capacity – arguably

myVC Patient feedback

• Saved one patient and a family member the day off work and over £50 in expenses

• Patients keen on alternating virtual appointments as they would like to maintain face-to-face contact

• “I really got a lot out of it and I think it is a very good solution for people like me” (Lives in Manchester)

• “Making audio recordings available is a big step towards empowering patients with greater access to their healthcare records”

Data Collector

Further discussion and questions

VOCALVirtual Online Consultations: Advantages and Limitations

Joe Wherton

Nuffield Department of Primary Care Health Sciences

University of Oxford

Aim

To define good practice and inform its

implementation in relation to clinician-

patient consultations via Skype™ and

similar virtual media.

Preliminary experience with remote consulting in Diabetes service –

‘DREAMS’ Study (2011-2014)

• 104 patients opted for Skype

• 480 Skype consultations documented

• popular with both patients and staff

• Associated with increased engagement: lower did not attend rates for

Skype (13%) compared to face-to-face (28%)

• Improvement to glycaemic control (HbA1c)

Background

1. What defines ‘quality’ in virtual consultations and what are the barriers to achieving this?

2. How is a successful virtual consultation achieved in an organization whose processes

and systems are mostly orientated to more traditional consultations?

3. What is the national-level context for the introduction of virtual consultations in NHS

organizations and what measures might incentivize and make these easier?

VOCAL: Virtual Online Consultations: Advantages and

Limitations(2015-2017)

Study DesignTwo clinical settings: Diabetes and Cancer Surgery

MICRO: Interactional dynamics via Skype by generating a multi-modal

dataset (audio, video and computer screen capture).

MESO: Map the administrative and clinical processes that will need to

change to embed online consultations

MACRO: National policymaker and other key stakeholder perspectives

Study DesignTwo clinical settings: Diabetes and Cancer Surgery

MICRO: Interactional dynamics via Skype by generating a multi-modal

dataset (audio, video and computer screen capture).

MESO: Map the administrative and clinical processes that will need to

change to embed online consultations

MACRO: National policymaker and other key stakeholder perspectives

• Trust policy and service agreements

Technical support, Information Governance

• Management and administration

Recording attendance, Appointment scheduling

• Clinical practice

Patient enrollment and setup, Medical documentation, Patient initiated

contact

Organisational change (meso level)

• Guidance and SOP documents

• Inform routine practices

• Facilitate coordination and shared learning (e.g. working group)

Supporting service development

What next? Health Foundation Scale up award

Seek to support spread of virtual consultation services by:

• Creating a virtual consultation unit (VCU) to facilitate local and national roll-out,

and sustained improvements

• Developing a national network, with new sites acting as local hubs for further

spread

• Working with national-level decision makers to jointly develop standardised

policy (e.g. on tariff, quality assurance, staff training)

• Evaluating the work, continually reflecting on mechanisms for change