scottish executive health department directorate of …patient pathway management referral...
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Patient PathwayManagement
Referral Facilitation
w w w . s c o t l a n d . g o v . u k
© Crown copyright 2007
This document is also available on the Scottish Executive website:www.scotland.gov.uk
RR Donnelley B50333 03/07
Further copies are available fromBlackwell's Bookshop53 South BridgeEdinburghEH1 1YS
Telephone orders and enquiries0131 622 8283 or 0131 622 8258
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Scottish Executive Health DepartmentDirectorate of Delivery
Scottish Executive, Edinburgh 2007
Patient PathwayManagement
Referral Facilitation
Scottish Executive Health DepartmentDirectorate of Delivery
ii
© Crown copyright 2007
ISBN: 978-0-7559-5350-9
Scottish ExecutiveSt Andrew’s HouseEdinburghEH1 3DG
Produced for the Scottish Executive by RR Donnelley B50333 03/07
Published by the Scottish Executive, March, 2007
Further copies are available fromBlackwell’s Bookshop53 South BridgeEdinburghEH1 1YS
100% of this document is printed on recycled paper and is 100% recyclable
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CONTENTS
Page
Executive summary 1
1. Introduction 2
2. The Benefits 5
3. Patient Pathway Management 7
4. Referral Facilitation 10
5. Referral Information Services 12
6. Referral Management 14
7. Costs 15
8. Making the Change Happen 16
9. Conclusions and Recommendations 18
10. Resources 21
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Delivering for Health requires NHS boards to develop three year implementation plans to introducethe five simple changes. The second simple change is to improve referral and diagnostic pathways.This document sets out recommendations of how appropriate clinically driven improvement of thereferral process in NHSScotland can:
• Use resources more effectively and fairly – freeing up clinical time to focus on clinically needypatients;
• Improve patient outcomes;
• Improve service quality;
• Improve overall value for money;
• Reduce long standing variations in treatment and pathways;
• Improve appropriateness of care – to make sure that patients get the right treatment, from theright professional, in the right place, at the right time.
To form this guidance the Planned Care Improvement Programme has reviewed pilot ReferralManagement and Information projects run as part of the Outpatients Programme in Scotland,reviewed experience from England, Wales & Northern Ireland and international best practice.
The programme promotes Patient Pathway Management as the strategy that binds together theredesign of services for the benefit of the patient and delivery of sustainable performance. PatientPathway Management promotes the reduction of variation in patient journeys, by means of theadoption of best practices implemented by the right people, in the right place, at the right time.
Effective Patient Pathway Management consists of the following key components:
• Evidence-based process design
• Referral Facilitation
> Referral Information
> Referral Management
• Booking and Access Guidelines
> Patient Focussed Booking
> Direct Access
• Patient Tracking, Management and Navigation
This document focuses on referral facilitation, information and management.
Executive Summary
1. Introduction
The complexities of waiting and queuing systems in healthcare have long remained an inexactscience and are borne out of a complex chain of events. These include referral, outpatient activity,decisions to admit, offers of admission, elective admission, treatment and discharge. This process inits entirety makes up a patient’s pathway through the healthcare system.
Delivering for Health requires NHS boards to develop three year implementation plans to introducethe five simple changes. The changes are designed to raise the performance of all NHS boards byenabling more care to be delivered locally, ensuring that patient pathways are planned in advanceand that patients experience seamless treatment with the minimum of delay whilst being kept fullyinformed and involved in their programme of care.
The second simple change is to improve referral and diagnostic pathways. Evidence suggests thatreferral between primary and secondary care and access arrangements for diagnostic tests oftencreate bottlenecks in the system. Delivering for Health outlines that referral pathways must bedefined with clear protocols and implemented in practice with the following key characteristics:
• Electronic referral to a central point;
• Referral to a service and not to a consultant unless there are clear clinical reasons forreferring to a named individual;
• Waiting list management;
• Flexible working practices;
• New roles and competencies.
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Patient Pathway
Initial Appointment
GP/Other Outpatient Outpatient Daycase Inpatient StepdownCare
OutpatientSimpleTests
ComplexTests
NonSurgical
Diagnostics Treatment Followup
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A report by the King’s Fund found that successful organisations had begun to look in detail at thelogistics of their hospital care processes. This involved looking at the patient process and attemptingto simplify and shorten it, identifying bottlenecks and pinch points for the individual process, andthen using the whole – hospital system perspective to work out, for example, the best way ofhandling the flows into and through the process.
Within these broad strategies successful organisations employed a host of additional measuresincluding tight bed management, maximising day case activity, ensuring full utilisation of theatresand effective discharge planning. These were supported by an understanding of the nature of theirwaiting lists to provide greater control over the flows and movements of patients into, around andout of hospital. This need for visible management and control has become a strong driver forcentralised waiting list management and standardised booking and access guidelines.
These characteristics are applicable across the whole spectrum of planned care and diagnostics, inaddition to other areas such as Cancer, and Health Boards should produce robust plans for theimplementation of integrated referral facilitation systems for the benefit of all their patients.
Evidence has shown that today’s high performance organisations are characterised by high qualitystreamlined patient management systems combined with robust tracking and patient navigationand escalation tools. Experience at operational level has identified that high performance inmeeting performance targets is significantly helped by the use of active patient management andtracking and ownership of patients’ journeys by empowered clinical teams.
As the NHS in Scotland evolves to a model of greater care closer to home, it is essential that amethodology exists to both design and control the migration of services from the acuteenvironment. Patient Pathway Management is the overarching strategy for identifying andanticipating diverse patient and clinician needs and preferences in order to tailor systems,processes, communications and results. It is the glue that binds together the redesign of services forthe benefit of the patient and the delivery of sustainable performance.
Patient Pathway Management consists of the following key components:
• Effective, evidence-based process design;
• Referral Facilitation;
> Referral Information
> Referral Management
• Booking and Access Guidelines;
> Patient Focussed Booking
> Direct Access
• Patient Tracking, Management and Navigation
Definitions
Referral Facilitation provides the quality improvement framework to manage and understand thereferral process to ensure that it is clinically led, proactive, drives improvement in safety, decisionmaking, matches demand and capacity whilst maximising finite resources at this key entry point inthe patient journey. A good Referral Facilitation framework will understand local health needs, andidentify optimum pathways for patients coming into the healthcare system from GPs, whilst reducingthe variability in the referral process and the outcome and experience of patients. Section 5examines referral facilitation in greater detail.
Referral Information tends to focus on the production and rapid feedback of referral volumes andpatterns between primary care and hospitals, with additional benefits arising from the use ofinformation to start understanding the patient pathway its design and outcomes. Good information,based on the CHI number is at the heart of effective service planning.
Referral Management entails moving from a system that reacts in an ad hoc way to meetincreasing needs, to one which is able to plan, direct and optimise services in order to meet thelocal health needs with the available local, regional and national resources. Referral Managementis not about rationing access to acute hospital services, delaying referrals from GPs to hospitals orreducing clinical freedom, indeed where cost effective health care is underused demand for certainservices may need to be encouraged.
Referral Management Services add further value by adding clinical triage to route referrals to themost appropriate healthcare professional and location. This is a very effective way to optimisedemand, capacity and access across an area and offers the opportunity to keep up to date all thepossible referral options, waiting times and evidence based pathways of care. Booking can bealigned to referral management to further streamline the process of appointments and optimise thepatient pathway.
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2. The Benefits
There is a need to provide a logical referral facilitation framework that helps this happen andprovides opportunities to remodel the process of referring a patient from a GP for furthertreatment. Furthermore a well designed referral facilitation process will assist health boards achievebenefits across the following key dimensions:
• Quality – by using the design, planning and ongoing maintenance and review of the referralprocess as a natural “home” for the discussion, agreement and communication of patientpathways, the overall quality of treatment will benefit by application of the best knowledgeavailable at the time.
• Access and waiting time targets – the redesign and management of whole patient pathways willensure that waiting and access targets can not only be met, but also maintained sustainably intothe future. Well designed referral facilitation and management services are integral to this vision.
• Patient Experience – the redesign and development of strong local services responsive to localneeds will benefit patients and help stabilise secondary care configurations. The detailedinformation that can be obtained from an integrated referral process will help to manage systemperformance and also allow planning of future provision in a proactive rather than reactivemanner.
• Effective evidence-based process design – Clinical teams who have redesigned patient journeyshave consistently achieved waiting time targets. Sustained performance and effective processdevelopment, implementation and evaluation across organisational boundaries will support thedelivery of sustainable performance. As follows:
• Effective pathways will pull patients through the system and will require minimumintervention and support;
• Effective pathways require to be agreed by all providers/stakeholders along the patientjourney and should exhibit the following characteristics:
• strong teamwork and clarity of process coordination;
• clear timings for each step.
• Improved data – referrals will no longer be based on inadequate information such as out ofdate waiting times, secondary care capacity, etc.
• Improved options – there will be greater opportunities for working across practices, andmaximising skills available in primary care. Updated Directories of Services will ensure thatpatients are directed immediately to the most appropriate healthcare professional.
An additional benefit of designing and implementing a Patient Pathway Management strategy is areduction in the variation of referral leading to:
• Better planning and scheduling of resources.
• Planned alternative referral and treatment routes that speed up access and reduce waiting times,allowing patients to be seen by the right person, in the right place, at the right time.
• Centralised points of referral that minimise the number of queues and simplify communicationsfor patients, healthcare professionals and the administrative and support teams.
• Improved information to address the variation in queues, treatments and outcomes and amechanism to gather local, regional and national referral information in order to optimise use ofresources.
• Clear rapid signalling processes in the system that can alert all teams involved in a patientprocess about changes in service provision due to unforeseen circumstances such as absence,illness or interruptions to normal service.
• Improvements in queue management through pooled lists and streamlined patient processes.
• Reductions in the cost of follow-up appointments.
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3. Patient PathwayManagement
Patient Pathway Management is the strategy for identifying and anticipating diverse patient andhealthcare professional needs and preferences in order to tailor systems, processes,communications and results. It is the glue that binds together the redesign of services for the benefitof the patient and the delivery of sustainable performance.
In a 2005 report, the King’s Fund identified successful strategies into sustaining reductions inwaiting times, and found that successful systems understood whole systems and the importance ofsustained action over time. Successful organisations started to address the task of reducing waitingtimes in a systematic way and persevered with the task. In addition successful organisations knewthat tracking individual patients through the hospital system is vital.
The work of the Cancer Services Collaborative in England has led to a greater understanding of thekey factors in achieving sustainable performance in meeting waiting times and this learning isapplicable to all healthcare delivery systems, for the benefit of all patients. Those delivering>95% achievement have in place effective pathways, high quality streamlined services combinedwith robust tracking, navigation and escalation systems. These criteria are all directly applicableand relevant to the creation, implementation and utilisation of referral facilitation and managementsystems in Scotland.
Patient Pathway Management
Effective evidence-basedpathway design
Referralfacilitation
Booking andaccess guidelines
Patient managementand navigation
The need for information has been a strong driver for centralising waiting list management and allsuccessful organisations recognised the need for much greater control over the flows andmovements of patients into, around and out of their hospital. The successful organisations usedcapacity planning models and ensured that they had access to the right information to plan forchanges in demand and consequent changes in capacity. The best were able to show how theytried to match capacity proactively with planned workloads as well as reviewing outcomes andunderstanding discrepancies. They listed the following as key elements in the management of theelective care system (King’s Fund January 2005):
• Introduce booking systems of notional (patient focussed) booking across all outpatient slots,inpatient and day case treatments, and tests and procedures.
• Ensuring that the progress of patients through the elective system is traced by using a uniqueidentifier such as the CHI number, enabling estimates of total average waits in different parts ofthe system to be identified.
• Improvement of the referral process with the aim of reducing unnecessary referrals and clinicvisits through, for instance, the use of protocols, and other forms of closer working betweenprimary and secondary care.
• Production of a directory for each specialty, with estimates of time taken per service, and the levelof expertise required. Using this directory hospitals should produce a detailed profile of capacityand demand for services and plan schedules accordingly for current configurations.
Patient Pathway Management builds on all these concepts and should assess from a strategicperspective the needs of patients and healthcare professionals and then adjusts services andprogrammes to meet these needs.
The Planned Care Improvement Programme is fundamentally involved with the whole patientjourney from GP referral to specialist follow up care. In order to successfully manage the processesthat form today’s patient journeys requires a successful patient pathway management system basedupon the successful integration of: a stratified identification of needs, full knowledge of local andregional capacity and demand levels, patient management systems and underpinning knowledgesystems along the full patient journey.
Patient Pathway Management should sequence all the relevant improvement and treatmentmethodologies in a synchronised approach to deliver improved healthcare and act as the integratorbetween disparate parts of the healthcare system to improve both clinical outcomes and patientsatisfaction. It should deliver:
• A safe process with clear lines of accountability and full clinical engagement between primaryand secondary care.
• Clearly identified key stages in the patient pathway with clinically validated and agreed solutions thatfocus on the whole patient pathway from GP referral to diagnosis, treatment options and follow up.
• A process that is straightforward and reliable, that minimises transfers between healthcareprofessionals, and manages queues effectively directing patients speedily onwards to the correctclinician, nurse, AHP or investigative test by means of appropriate referral protocols and triaging.This means that the process has to have comprehensive coverage of all referrals and make useof appropriate single points of contact and alternative treatment options.
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• A process with good information and good data at its heart. This can be ensured by having highquality information on which to base decisions available at each step of the process. Thisincludes referral guidelines, information to be provided to the secondary care provider, servicestatus feedback to the referrer and an education process to update the pathway protocols in thelight of new local circumstances or changes in best practice guidance.
Patient Pathway Management consists of a number of different elements as shown above and thefollowing sections look in more detail at the Referral Facilitation, Information and Managementcomponents and the contribution they play in the whole patient pathway management process.
4. Referral Facilitation
Simply put, Referral Facilitation provides the quality improvement framework to manage andunderstand the referral process to ensure that it is clinically led, proactive, drives improvement insafety, decision making, matches demand and capacity whilst maximising finite resources.
Referral Facilitation contains a spectrum of activities ranging from simple Referral InformationServices at one end of the spectrum to integrated Referral Management & Booking Services at theother, with the most advanced systems displaying elements of both these processes. A good referralfacilitation framework will fully understand local health needs, and identify optimum pathways forpatients coming into the healthcare system whilst reducing the variability in the referral process andthe outcome and experience of patients.
A referral facilitation framework should have clearly defined and agreed patient pathways withagreed referral protocols for all referrals between primary and secondary care and clear timelinesidentifying the key events that need to occur and the relevant escalation points all along thesubsequent patient pathway.
An effective Referral Facilitation framework will help clinical teams make improvements in thefollowing key areas:
Patient Focus: by keeping patients at the heart of the process we ensure that the design of patientpathways through the healthcare system is smooth with the minimum of delays and waste.
• By defining value from the patient’s perspective it is possible to identify activities that help treatthe patient as value adding, whilst anything else is waste.
• Focussing subsequent improvement efforts on the things that matter to patients and healthcareprofessionals and the things that get in the way of delivering effective care, will producestreamlined and validated patient pathways.
• A clear patient focus will ensure that each step in the process has been designed with an eye tothe overall effect it has on the steps before and after it in order that they link together seamlesslyand minimise the patient’s overall journey.
• A well-designed pathway modelled to deliver services in a patient focussed way, closer to homewith fewer and quicker appointments. This entails utilising the full breadth and depth ofappropriate healthcare professionals and services available to the system from both primary andsecondary care and altering existing patient pathways for provision now and into the future onthe basis of the effective use of primary and secondary care data.
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Safety: Improved data quality and standardised processes, including universal use of the CHInumber, will ensure that systems of referral and waiting list management are safer for patients.Quality may also be improved by assessing the appropriateness of referrals against guidelines andinforming generalists where referrals do not meet the acceptance criteria. By ensuring that clearaccountabilities and timelines are defined and documented there is less opportunity for delay, lossand error in the referral process.
Clinical Quality: Patients seen by the most appropriate healthcare professional in the shortest timepossible. The work in properly involving both primary and secondary care enables primary care tobe fully engaged in the Planned Care agenda and the sharing and developing of good practiceduring the creation of referral protocols and guidance will promote effective practices betweenprimary and secondary care. The creation of clear, standardised processes creates a platform forcontinuous improvement by addressing the following issues:
• Reducing variation in the quality and number of GP referrals;
• Creation of comprehensive directories of services;
• Primary care obtained feedback of referral data for specialties;
• Shared understanding of changing models of service for our changing demographics.
Access: Designing systems with a single point of contact and pooled lists helps to reduce consultantwaiting times and an effective referral management system will provide services to patients in atimely fashion. The improved utilisation of alternatives to consultant care will help to speed upaccess times with Consultants seeing more complex cases in their clinics and as a result havehigher conversion rates, spending less time in Outpatients and more in surgery.
Efficiency: an effective referral management system will support overall system efficiency bystreaming work to areas of unused capacity. When integrated with PFB there are potentialimprovements in DNA and cancellation rates. To achieve this requires:
• Collating referrals to produce data on their volume, direction and quality and thus helpmanagers and healthcare professionals develop services and service specifications;
• Better demand data to help improve capacity planning;
• Streamlined referral routes with one route, single queues and single points of contact and pooledreferrals of patients within specialties that will help optimise patient journeys;
• A thorough knowledge of capacity and demand for all services on the pathways that will allowfor better utilisation across a board;
• Agreed protocols for diagnosis/initial consultation and investigation that direct patients straight totest or alternative treatment and combine tests and visits into one or two visits;
• Extended roles for nurses and other AHPs to reduce the requirement on consultant-led activities;
• Agreed protocols and contact mechanisms for redesigned services.
Historically there has been an information gap in the referral process between primary andsecondary care, where GPs have tended to receive very little feedback about the process until theirpatient returns from an appointment.
A Referral Information Service deals largely with area wide statistical data and can be located in aphysical or virtual centre and it will tend to focus on the production and rapid feedback of referralvolumes and patterns between primary care and hospitals. Referral information is a key step tocollecting information on demand and to working within primary care and community services tofinding alternatives. It will provide baseline information to allow for redesign to take place.
There are essentially 3 levels at which a system may operate a referral information service.
Level 1 – GP referrals pass through the service and anonymous information on numbers, specialty,hospital and consultant are collated.
Level 2 – As above, but GP practices are provided with personalised feedback on numbers androutes of referrals.
Level 3 – As above, plus the options to identify referrals to specialists or centres with shorter waits.
CCI funded two Referral Information Service pilots from over 17 months to December 2005 andlearned several valuable lessons. Almost universally, the pilot projects reported difficulty generatingreferral information data of sufficient scope and quality to prove useful as a tool in themanagement of demand for secondary care outpatient appointments, within the lifetime of theproject. However, the pilot sites continued to develop their work because of the potential benefitsfor patients and local NHS systems.
The pilots identified the issues of over reliance on IT infrastructure and software to generate thenecessary information and how without the necessary proven services and equipment in place, it isextremely difficult to generate the data required to manage the system.
“It would be better to have an administrative system in place and operational before introducing ITsystems…processes that have evolved through the actual working practices of clinicians should bebuilt upon by the technology.”
In the intervening period, however, there has been progress on a number of fronts and there is nowevidence of systems that can offer good data for analytical purposes. However, in order tomaximise their contribution to the patient pathway management process it is important to designreferral information services as more than purely administrative systems.
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5. Referral Information Services
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The October 2005 report by The National Primary Care Research and Development Centre,looking at research into strategies for improving outpatient effectiveness and efficiency, identified anumber of interventions shown to be effective in reducing outpatient demand. These includededucational outreach by specialists in activities to support development of local referral guidelinesand the creation of structured referral protocols. In the same report, however, it was alsohighlighted that strategies based on passive dissemination of referral guidelines, audit andfeedback of referral rates and the discussion of referral behaviour with an independent medicaladvisor alone were ineffective interventions.
In order to achieve the benefits to the system, healthcare professionals need to be fully engagedand view referral management as a process that adds value to their decisions, streamlines theprocess, and makes the patient’s journey more efficient and transparent. This requires a processwithin an integrated and coherent referral facilitation structure that moves beyond simply analysingand redirecting referral information, to active design and management of patient referral pathwaysand the location of services and those who provide them.
6. Referral Management
Referral Management entails moving from a system that reacts in an ad hoc way to meetincreasing needs, to one which is able to plan, direct and optimise services in order to meet thelocal health needs with the available local, regional and national resources.
Referral Management is not about rationing access to acute hospital services, delaying referrals orreducing clinical freedom, indeed where cost-effective health care is underused demand for certainservices may need to be encouraged.
Traditionally, referral management has been the preserve of routine referrals but is increasinglybeing used for urgent referrals to improve cancer waiting times. By receiving urgent referrals at acentral point, patients can be tracked and processes expedited to ensure that breaches against thetarget are eliminated.
Referral Management Services add further value by adding clinical triage to route referrals to themost appropriate healthcare professional and location. This is a very effective way to optimisedemand and capacity across an area and offers the opportunity to keep up to date all the possiblereferral options, waiting times and evidence based pathways of care. Booking can be aligned toreferral management to further streamline the process of appointments.
Referral Management Services enable a more sophisticated single point of referral from GPs andother healthcare professionals within primary care. The referral management service will either treatimmediately, perform first stage diagnostics and/or arrange the most appropriate appointment,either within primary care or at the hospital. Pathways can be developed, implemented andmonitored and booking can be added to the process where appropriate to maximise coordinationof activities. GPs can refer patients to GPs with special interests or to other healthcare professionalswithin primary care as well as the acute sector.
The NHS Institute for Innovation and Improvement report “Making the Shift: a review of NHSexperience” (July 2006) describes common features of initiatives that have successfully supported ashift in the balance of care. Within the report there was agreement that referral management wasmost successful as part of a clinical assessment and treatment service. Many areas that hadestablished referral management centres using a purely administrative model had either ceased orwere planning to cease as in isolation they were seen to add complexity to the process.Simplification occurred through the use of community specialists to assess and treat where possible.
Where referral management services are not clinically led, and the model does not add any valueto the patient journey, they become purely a mechanism for managing demand. Such referralservices are not acceptable.
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7. Costs
A referral service is not cost neutral, there will be costs to setting up referral services such as thevariable set up costs dependant upon the setting such as:
• the cost of introducing alternative primary led services;
• the cost of information collection and analysis;
• the cost of training new/existing staff to appropriate level;
• the cost of equipment, e.g. upgrades to telephony and or knowledge management systems;
• where the referral service is located, i.e. is it within an existing outpatient facility or is it located ina dedicated contact centre, what economies of scale are available when utilising existing facilitiesand staff/IT systems?
• the size and scope of service being handled by the referral management service;
• the baseline of services being managed by the referral management service, i.e. how manyservices need to be redesigned prior to implementation;
• the cost of documenting and systematising new services;
• the scale of IT being used;
• the cost of wide scale communication and consultation about enhancements or modifications toservices.
As a benchmark, the Audit Scotland 2003 census report “Outpatients Count” estimated the averagecost of a consultant appointment as £65, however this ignores significant whole system savingsgenerated by streamlining patient pathways (having fewer unnecessary consultant appointments),reducing overall numbers of referrals (using referral protocols and GP feedback) and appropriatelyreturning patients to the care of their community service (e.g. GP).
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8. Making the change happen
Planned Care provision is complex. It involves community and hospital care and back again, it cancross interagency boundaries and it can also involve the independent healthcare sector. The currenthealthcare system in Scotland does not manage referrals from Primary to Secondary care in thebest way possible.
This inefficiency in process is now colliding against the strategic direction to provide services closerto home and the need for a framework to help plan and deliver this change. Evidence from“Making the Shift” (2006) has shown that key success factors in leading this transformation haveincluded:
• The development of strong relationships between GPs and Consultants through facilitatedredesign workshops;
• Strong Clinical leadership to overcome resistance to change;
• The development of GP peer review of referrals;
• High quality information management and technology often with local solutions;
• Robust information systems to provide all clinicians with accurate and real time data to supportservice developments;
• Support of the Royal Colleges to ensure acceptability in service redesign.
The Planned Care Improvement Programme recommends that NHS boards ensure outpatientpathways are utilised and form part of the wider clinical systems redesign to find clinicallyappropriate outpatient treatment. These pathways should include the following interventions thathave been shown to be effective in optimising the use of scarce resources:
• Discharge of outpatients to either no follow up, patient initiated follow up or GP follow up asalternatives to routine follow up in hospital outpatient clinics;
• Use of GPs with special interests;
• Direct access for GPs to hospital based diagnostic tests and investigations or hospital treatmentswithout the prior approval of a specialist in an outpatient clinic;
• Structured referral sheets which prompt GPs to conduct any necessary pre-referral tests ortreatments and educational support by specialists in creation of local referral guidelines;
• Transfer of medical care for common chronic conditions such as diabetes from secondary toprimary care;
• Development of teams and team leaders that work across primary and secondary care to reducethe need for treatment within acute services;
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• Provision of alternative routes of care that are coordinated by means of referral managementservices.
The Planned Care Improvement Programme will encourage health boards to introduce referralfacilitation frameworks that drive the use of referral information and promote redesign of existingservice delivery models to incorporate referral management services. This will help in both thestrategic shift in the balance of care and the effective utilisation of scarce resources at both localand regional levels.
The Planned Care Improvement Programme will assist boards to share ideas and best practice andfacilitate visits and knowledge exchange with healthcare systems outside Scotland. It is recognisedthat Health Boards will be starting out from different positions, however, key components of plansshould include:
• Identified clinical leads and dedicated project management time;
• A commitment to ensure that outpatient pathways in high volume specialties are adopted (oradapted to suit local circumstances) and are integrated into wider clinical systems redesign;
• A clear understanding of current referral patterns for specialties and their associated waitingtimes and/or degrees of urgency. Boards should be able to measure the volume of patients towhom patient pathways apply and be able to analyse local variation from patient pathwayssupported by CHI as the unique patient identifier;
• A clear understanding of community based services and the potential shift available from anacute environment and clear evidence of engagement with community health partnerships in theprocess of service redesign;
• A commitment to implement patient pathways across long wait specialties and the use of healthprofessionals who have undertaken additional training in their chosen specialties (such asextended role Nurse Practitioners) to help promote the spreading and sharing of existing goodpractice;
• Boards should have a clear view of the possible redesign of services and subsequent alternativereferral routes this offers, including referral management services. Boards should be able topromote the effective use of patient pathways and extended role practitioners;
• Identification of local high volume specialties that will implement integrated referral systems;
• A commitment to decrease the requirement for return outpatient appointments in high volumespecialties and to maximise follow up at, or close to home;
• A plan to integrate referral management and booking services.
Referral facilitation and management are key to delivering the shift in the balance of care outlinedin Delivering for Health and effectively deliver the simple change number 2, improving referral anddiagnostic pathways. The previous chapters are a description of best practice and the elements thatreferral facilitation must include to be truly effective.
NHS boards should ensure that the following are planned and implemented over the next threeyears:
• Introduce booking systems of patient focussed booking across all outpatient slots, inpatient andday case treatments, tests and procedures;
• Ensure patient progress along pathway is traced using CHI, enabling estimates of total averagewaits in different parts of the system to be identified;
• Improve the referral process through the use of protocols and other forms of closer workingbetween primary and secondary care;
• Produce a directory for each specialty, with estimates of time taken per service and the level ofexpertise required;
• Produce a detailed profile of capacity and demand for services using the directory and planschedules accordingly for current configurations;
• Produce clearly defined and agreed patient pathways with agreed referral protocols for allreferrals between Primary and Secondary care;
• Assess the appropriateness of referrals against guidelines and informing generalists wherereferrals do not meet the acceptance criteria;
• Design systems with a single point of contact and pooled lists;
• Ensure clinical triage is an integral part of any referral management service to route referrals tothe most appropriate healthcare professional and location;
• Understand the models behind referral facilitation and management systems and identify gaps inthe local adoption and spread of the methodology.
• Apply the following 5 key principles to referral facilitation projects.
> Clinical engagement;
> Clear accountability;
> Patient Safety;
> Effective use of primary and secondary care data;
> Comprehensive coverage of all referrals.
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9. Conclusions andrecommendations
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• Expand upon the work done to implement referral management locally and incorporate PFB inan integrated process.
> By linking referral services to current booking and PFB process using CHI as the uniquepatient identifier, boards will be encouraged to combine referral management and bookingin outpatient or day case environments;
> Actively promoting the evolution of current booking facilitation centres, located inoutpatients, into referral facilitation centres in order to make best use of staff, ensurethat data collection is optimised and patient pathways are updated.
• To spread the early successes and lessons learned in Scotland in orthopaedic redesign and thecreation of referral management services.
> Matching services provided to the local population needs and producing a comprehensivedirectory of local services;
> Remodelling services to provide alternatives to consultant led clinics and shift the balance ofcare away from acute sites and develop enhanced community provision;
> Work with community health partnerships to remodel service provision;
> Providing patients with assessments, diagnostic tests and treatments for a wide variety ofconditions in a primary care setting;
> Actively manage referrals between primary and secondary care to ensure theappropriateness of service provision at every stage of the pathway.
• It is recognised that Health boards will be starting out from different positions, however thePlanned Care Improvement Programme recommends that all boards produce a key eventtimetable as part of their three-year implementation plan as illustrated overleaf.
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Key Project Components 06-07 07-08 08-09
Boards should have clinical leads and project managers inplace.
Boards should produce a directory of current servicesoffered.
Boards should have a clear understanding of currentreferral patterns for specialties and their associated waitingtimes and/or degrees of urgency. Boards should be able tomeasure the volume of patients to whom patient pathwaysapply and be able to analyse local variation from patientpathways.
Boards should map existing queue management processesand systems across all specialties in order to reduce carveout and achieve single waiting lists.
Boards should ensure that patient focused booking systemsare being further implemented across all specialties inorder to align capacity and demand for services.
Boards should audit specialties for alternative pathways andlist by priority specialties for redesign.
Boards should have clear understanding of communitybased services and the potential shift available from anacute environment and clear evidence of engagement withcommunity health partnerships in the process of serviceredesign.
Boards should be able to demonstrate a commitment toimplement patient pathways across long wait specialtiesand promotion of extended role practitioners in addition tothe spreading and sharing of existing good practice.
Boards should establish a referral facilitation framework.
Boards should have a clear view of the possible redesign ofservices and subsequent alternative referral routes thisoffers, including referral management services. Boardsshould be able to promote the effective use of patientpathways and extended role practitioners.
Boards should systematically review and remodel allspecialties to ensure that the most appropriate pathwaydesign is provided for each specialty.
Boards should establish and make available electronicreferral pathways and patient management guidance.
Boards should actively move towards target of 90%electronic referrals.
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10. Resources
Included in this guidance is a CD resource pack that contains the following material:
• NHS Institute for Innovation and Improvement, “Making the Shift: A review of NHS experience.”July 2006
• National Primary Care Research and Development Centre, Outpatient Services and PrimaryCare, October 2005
• IST, Referral Facilitation and the new GMS contract
• CCI, CHI utilisation on referrals by NHS Board
• King’s Fund, Sustaining reductions in waiting times: Identifying Successful Strategies, January2005
• Department of Health, Sustaining Cancer waiting times through effective pathway management
• NHS MA, Secondary care booking: towards a fully booked NHS, August 2004
• NHS MA, The Big Wizard, Demand Management, September 2002
• NHS MA, The Little Wizard, Demand Management, December 2001
• CCI, Referral management pilot site evaluation, March 2006
• CCI, Referral information pilot site evaluation, February 2006
• CCI, Patient Pathways, PowerPoint edition, November 2005
• CCI, Patient Pathway, PDF edition, November 2005
Patient PathwayManagement
Referral Facilitation
w w w . s c o t l a n d . g o v . u k
© Crown copyright 2007
This document is also available on the Scottish Executive website:www.scotland.gov.uk
RR Donnelley B50333 03/07
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