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SPECIAL REPORT

Improving the Efficiency and Effectiveness of the Referral Process Avoiding Referrals Through Clinical Dialogue Hospital Referrals: The Big Challenge for the NHS The Battle Against Referrals How to Improve Your Referrals Healthcare and the Digital Future

Sponsored by

Published by Global Business Media


Saving Referrals through Clinical Dialogue Kinesis is a secure web-based cloud solution that directly links GPs to hospital specialists to rapidly gain expert advice on patient treatment option, as an alternative to a referral.

50% of Kinesis conferrals result in an avoided referral, allowing more patients to be quickly and successfully treated in the community by their GPs and having a positive impact on outpatient clinics, GP knowledge and patient outcomes. Simple to use, easy to adopt and with enthusiastic adoption by both GPs and Consultants, Kinesis is revolutionising GPs’ referral practices.

www.kinesisgp.co.uk

Allows GPs and consultants to agree appropriate treatment for patients quickly and securely

Reduces the time to treatment, with more patients treated successfully in the community

Reduces referrals and substantially reduces referral costs

Enables clinical dialogue and education

Tel: +44 (0)7735 052905

Kinesis is a registered trademark of Cloud2 Ltd.

Join the conversation on Twitter @KinesisGP


IMPROVING THE EFFICIENCY AND EFFECTIVENESS OF THE REFERRAL PROCESS

SPECIAL REPORT

Improving the Efficiency and Effectiveness of the Referral Process Avoiding Referrals Through Clinical Dialogue Hospital Referrals: The Big Challenge for the NHS The Battle Against Referrals

Contents

How to Improve Your Referrals Healthcare and the Digital Future

Foreword

2

Tom Cropper, Editor

Avoiding Referrals Through Clinical Dialogue

3

Simon Hudson – Cloud2 Ltd

Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor Tom Cropper Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

Background Adoption of Kinesis Costs and Benefits Secondary Care Perception Future Conclusion

Hospital Referrals: The Big Challenge for the NHS Tom Cropper, Editor

Under Pressure Reducing Workload The Doctor’s Dilemma

The Battle Against Referrals

Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

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Jo Roth, Staff Writer

Improving the Process Faster Referral The Potential of the Web

How to Improve Your Referrals

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James Butler, Correspondent

Factors to Consider Getting Information

Healthcare and the Digital Future The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated.

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Tom Cropper, Editor

Business Intelligence Online Information Systems And the Future?

References

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© 2016. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

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IMPROVING THE EFFICIENCY AND EFFECTIVENESS OF THE REFERRAL PROCESS

Foreword T

HE NHS is under pressure, it seems, from

at the various options GPs have to reduce the referral

just about every quarter. With funds on the

rate. The NHS has tried everything from third party

way down and workload on the way up there is a

management to cash incentives and electronic referral

greater emphasis than ever before on efficiency

systems to make it faster and more efficient – all with

and process.

mixed success. However, new technologies can play

One of the key areas for improvement has been in the referral process. It’s slower than it needs to be

a role in providing GPs with more information and support which can improve the referral process.

with many communications still made via second

James Butler will then look at some of the things GPs

class post. And it’s inefficient – too many referrals are

should consider when planning a referral, before we

unnecessary or inappropriate. There is work to do to

examine some of the latest solutions in more detail.

improve the process from all perspectives.

Digital technology has the potential to transform the

As Simon Hudson of Cloud2Ltd writes in our opening

way we provide health services in this country. We’ll

article, much of the focus has been on making it faster,

focus on some of these systems and see how they

while there should be more on reducing inefficiencies

have worked in practice.

altogether. He highlights some of the evidence which

Referrals have been a sticking point for the NHS for

suggests Cloud2’s online information service, Kinesis,

some time. The question now is, can it take advantage

can reduce the number of referrals and help GPs to

of new technologies and new solutions to make them

make better decisions.

faster and more effective for patients?

Elsewhere in the report we’ll examine the challenges GPs are working against and the role referrals might have in reducing the workload. Jo Roth will then look

Tom Cropper Editor

Tom Cropper has produced articles and reports on various aspects of global business over the past 15 years. He has also worked as a copywriter for some of the largest corporations in the world, including ING, KPMG and the World Wildlife Fund.

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Avoiding Referrals Through Clinical Dialogue Simon Hudson – Cloud2 Ltd Improving Referrals should include referral avoidance strategies. A group of South London CCGs has been achieving impressive results in referral reduction simply by requesting expert clinical advice from consultants.

H

ERE ARE some things we can probably all accept as true: • GPs are seriously busy and can’t spend as much time as they would like with patients. • Accident and Emergency and outpatient clinics are experiencing unprecedented demand leading to extended waiting times. • The practice of medicine and the range of health conditions experienced by human beings is enormous and the full depth and breadth is beyond even the smartest of us. Obviously, GPs can’t know everything and are under pressure to make very rapid clinical decisions. If in doubt, the fallback position is, quite reasonably, to refer patients to the specialists at a hospital trust. There is a problem with this; most of these referrals are unnecessary1 and consequently introduce delays in starting appropriate treatment, which is to the detriment of positive clinical outcomes. There is not a lot that can be done about the bulleted problems above. However, a large number of GP practices in South London are doing something about the rate of referrals, with the support of specialists at an increasing number of local hospital trusts. Instead of reaching for the referral letter template (or firing up the new eReferral Service application), they now have the option to confer with their consultant colleagues using an innovative web-based technology called Kinesis. The results are impressive: typically, they have seen referral rates halved where a conferral takes place, resulting in better care for patients and learning for GPs, leading to better future referrals and substantial cost savings across the health economy.

Background NHS Midlands and East issued a report in January 2012: “Confer: End of Pilot Report”; this drew attention to “marked and ongoing increases in outpatient referrals” and discussed the demand management challenge for primary care commissioners and acute trusts. Evidence

presented claimed that “up to 65% of patients attending outpatient specialty clinics are discharged with no significant pathology being detected”2. Referral Management Centres have been a common response to the problem, but with mixed results. There’s been much emphasis on improving the referral process. For example, after a somewhat difficult gestation, eRS launched last year as a welcome replacement for Choose and Book. There has been remarkably little focus on avoiding referrals altogether, however. It is evident that some referrals are made because the GP desires expert advice on the further investigation of a patient in whom the diagnosis is not yet clear; others are made seeking advice on the most appropriate management of a known condition. Both these scenarios might be addressed by timely access to specialist advice rather than by referral; the Advice and Guidance module within Choose and Book was intended to address this need. However, it has largely failed to be adopted and no enhancements have been delivered as part of eRS. There are a limited number of other services and technologies that seek to address the same need; some provide on-call specialists as a service, some provide access to knowledge bases, while others provide a managed personal advice and response approach. There is a strong and growing body of evidence from a handful of South London CCGs that introduction of the latter type of system for GPs can have a marked impact on referral rate. The system adopted, called Kinesis, enables and encourages GPs to seek advice from specialists (known as a ‘conferral’) as an alternative to referring patients. It does this through a secure web application, and has a range of powerful features. However, its most important capability is that most clinical questions are answered within 24 hours, which is a clinically meaningful period of time and allows

Saving Referrals through Clinical Dialogue

Kinesis is a secure web-based cloud solution that directly links GPs to hospital specialists to rapidly gain expert advice on patient treatment option, as an alternative to a referral.

www.kinesisgp.co.uk +44 (0)7735 052905 @kinesisGP

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“The issue isn’t really about these savings, it’s about the improved patient care…” Dr Nicola Jones, chair Wandsworth CCG

FIGURE 1 - CONFERRAL PROCESS

patients to be entered into appropriate treatment far more rapidly than through a referral process. There are often existing mechanisms which particular specialty groups provide for providing advice, based on email and telephone. However, anecdotally, GPs using email etc. expect to receive an answer in around 5 working days –if at all – and this relies on the GP knowing the contact mechanism for the consultant. The general process is shown below.

Adoption of Kinesis Wandsworth CCG was an early adopter and have been tracking use of the system. Their data is interesting as a model for adoption: 2012/13 • Kinesis savings for the financial year 2012/13 were £22,385 (based on five months of activity since the pilot launch date). 2013/14 • By the end of March 2014 there were 2113 advice requests from GPs, with 1074 of these recorded as a ‘saved referral’ – a cost saving of £200 per referral • This is 47% of all advice requests, resulting in an achieved cost saving of £183,105 to date (this figure takes into account a £15 tariff per advice request). • 76% of requests were answered within 24 hours 2014/15 • In the April 2014 – March 2015 year there were 2869 requests for advice with 1660 of these saving a referral, 58% of conferrals avoided a referral. • Total net savings of the programme were calculated as £239,590, based on a nonface-to-face tariff payment to providers of £15 4 | WWW.PRIMARYCAREREPORTS.CO.UK

against a mean referral cost of £204. • 59% of requests were answered within 24 hours As the usage of conferrals continues to increase, there is a predictable decrease in the proportion of overall avoided referrals. This had reduced to around 54% overall by February this year as GPs explore patients with more complex conditions where it’s less clear that a referral might be avoided. This is not considered negative, as the number of referrals avoided continues to increase. GPs continue to request further specialties and, as awareness of the programme spreads, further specialties are coming on board and new trusts are becoming engaged. Currently St George’s Hospital provides 32 specialties, with 8 at Chelsea and Westminster, 4 at Guy’s and St Thomas, while South West London and Imperial are at the pilot stage. The hospital’s GP liaison officer plays a key role in keeping consultants informed and taking responsibility for the programme on behalf of the provider. Having a dedicated project manager at the CCG to drive the programme forward has been essential and is a key component in driving uptake, dealing with user issues and administration and with reviewing reports and processes to ensure the overall programme is a success.

Costs and Benefits The average cost of an outpatient clinic referral to commissioners is around £204. In most cases CCGs using the Kinesis system have agreed to pay the advising trust the non-face-to-face tariff (currently £15 - £25) for advice received that avoids a referral. Their analysis has shown that, after the cost of Kinesis and the non-face-


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Saving Referrals through Clinical Dialogue

Kinesis use

Appointment saved

No of conversations ‘NOT Closed’ byGPs on Kinesis

KINESIS USAGE

to-face tariff, there is an average saving of £151 per referral. “The issue isn’t really about these savings, it’s about the improved patient care…” Dr Nicola Jones, chair Wandsworth CCG However, it isn’t just about financial savings. The clinicians involved are very enthusiastic about this approach. GPs appreciate the ability to get good advice and reassurance through this conferral process and use it as an opportunity to improve their clinical knowledge while maintaining their relationship with their patients throughout the course of treatment. Equally, consultants appreciate being able to offer their expert advice in response to valid clinical questions as well as an overall increase in the appropriateness of those patients attending clinics, with the opportunity to have a more meaningful impact on them. When fully adopted, the expectation is that outpatient waiting lists will reduce and allow more rapid escalation of priority cases. “I just wanted to say that Kinesis is fantastic! It is great way to speak to specialists and get useful advice very quickly! “

Secondary Care Perception Wandsworth CCG have attributed the high level of support from St George’s Hospital as a critical factor in the success of the programme. Its chief executive has been particularly supportive, observing in open session that supporting this kind of initiative is essential regardless of potential revenue impacts. There have been some concerns from secondary care trusts that referral avoidance programmes might impact revenue for the

hospital due to reduced referrals. This has not been seen to date as there remains sufficient demand for clinic appointments. Consultants have been keen to participate as they recognise the value the programme adds and the number of specialties involved continues to increase. Consultants have really valued the ability to both aid their primary care colleagues and maintain a dialogue if a patient has been referred. There has been reservation about the additional load advice requests might place on consultants. However, the data and feedback indicate that they have not found involvement burdensome. Even heavily-used specialities are receiving only a handful of requests for advice per consultant per week. On average, the number of messages sent per conferral is 2.7, though the modal value is 1; the time spent responding to requests and messages by clinical staff is considered to be low.

Future The basic premise of GP-to-Consultant requests for advice is already being extended. GPs with Special Interests (GPSIs) are being brought onto the programme and other clinical areas, such as tissue viability, physiotherapy, etc. are also appropriate. Furthermore, the system is being used for the sharing of radiology images and other innovative uses. Another active user group, Sutton CCG, is aiming for a target of 10 conferrals per 1000 (weighted) population, during 2016/17, as a mechanism for encouraging use of conferrals as an alternative to referrals, though this is being monitored carefully to guard against spurious, target-driven conferrals. Meanwhile Her Majesty’s Prisons have also expressed some initial interest as a means of

Allows GPs and consultants to agree appropriate treatment for patients quickly and securely

www.kinesisgp.co.uk +44 (0)7735 052905 @kinesisGP

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“I just wanted to say that Kinesis is fantastic! It is great way to speak to specialists and get useful advice very quickly! “

TOP 6 SPECIALTIES

Conclusion

NUMBER OF MESSAGE EXCHANGES PER CONFERRAL

providing the same clinical expertise in order to avoid extremely costly secure transfers of prisoners to hospitals. Further applications include the possibility of using machine learning to identify potential diagnoses and previous advice (all heavily anonymised and encrypted) or even to act as an early warning observatory for emerging clinical conditions. In fact, this is already happening on a small scale with the identification of higherthan-average localised gout prevalence, leading to development of a clinical pathway.

With increasing rates of referrals, financial constraints on our primary care and secondary care services and the demographic and social influences counteracting improved population health, there is an urgent need to optimise referral patterns, to engage patients in the correct care as quickly as possible and to use our valued clinical experts efficiently. Better referrals are certainly part of that picture, but referral avoidance is equally important. The evidence is that a balanced portfolio of technology and programmatic change can deliver substantial benefits across the board. If such systems were adopted nationally the savings have been estimated as being in the £200m to £800m range in direct referral savings and indirect improved health/avoided treatment costs.

Contact Cloud2 Ltd 2nd Floor, The Wool Exchange, 10 Hustlergate, Bradford, West Yorkshire, BD1 1RE 01274308378

References: 13% during 2008/09 HES online; www.hes.nhs.uk NHS Institute for Innovation and Improvement. Delivering Quality and Value Focus on: Productivity and Efficiency. April 2009

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Appendix 1 – Further information: Kinesis on the web – http://www.kinesisgp.co.uk/ NHS England case study PDF: https://www.learnenv.england.nhs.uk/pinboard/download/id/111 NHS England Case Study Site https://www.learnenv.england.nhs.uk/pinboard/search

Articles on referral management: PULSE Up to one quarter of GP referrals ‘avoidable’ http://www.pulsetoday.co.uk/up-to-one-quarter-of-gp-referrals-avoidable/20007690.article#.U_8uj3l0yiM Dept of Health http://departmentofhealth.ideascale.com/a/dtd/Kinesis-GP-referrals-and-more/40853-15482

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Hospital Referrals: The Big Challenge for the NHS Tom Cropper, Editor High demand, pressure on costs and a shortage of infrastructure all increase focus

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Saving Referrals through Clinical Dialogue

on hospital referrals.

I

N JUNE this year a leaked consultant’s letter raised concerns about the quality of care being given to pregnant mothers and their unborn babies. In some instances, it said, doctors were holding onto patents who needed specialist care because they could afford to pay the fees. As a result, more patients were being put at risk because of funding constraints within the NHS – or as the Daily Mail decided to put it: “Babies needlessly dying and mothers put in harm’s way because NHS funding battle is ‘stopping urgent referrals3‘”

Under Pressure It’s the kind of story which has, and always will be, staple fodder for the Daily Mail. But beneath it all is one of the key challenges facing the NHS. Funding is short, demand is growing and the referrals process is coming under increasing scrutiny. A growing and aging population means GPs are dealing with more patients and increasingly complicated cases. A recent study suggested GP practices were seeing 80 more patients each week. Over the past seven years, workloads have increased by 16% and some consultancies are processing 200 appointments every day4. The number of weekly consultations per practice has risen from 902 in 2007 to 984 in 2014. Face to face consultations are up by 6.38% while telephone consultations have doubled. The population is growing. Official ONS figures suggest the UK population could rise from 64.6million to 74.3 million by 2039 – and it’s getting older5. Ironically the success of the healthcare system in treating more people more effectively means they are inevitably living longer and increasing the complexity of cases seen at the primary care level. At the same time, funding for the NHS – and primary care in particular – is under pressure. In 2015 the NHS was rocked by news that trusts had racked up a deficit of £1bn in the first three

months of the financial year6. By the beginning of 2016 trusts were forecasting a deficit of £2.3bn. A survey from the Kings Fund found that the majority of respondents believed care quality was deteriorating in their area7. Primary care has faced more stringent restrictions than most. The Kings Fund also found that the share of the NHS budget dedicated to primary care had fallen from 8.3% to 7.9%8. Workload has been outstripping recruitment, despite government ambitions to recruit more staff. The NHS recently produced a £206million plan to hit the government target of recruiting 5,000 more GPs by 2020. However, the actual numbers are, if anything, moving in the other direction. In February 2016 a survey of 3,000 practices found that half of all doctors were considering leaving the profession9. Much of the growing work-load comes in the form of increasing administration pressures. Although there has been a small increase in admin staff in general practices, it is nowhere near enough to cope with the demands. So, when it’s impossible to increase infrastructure and staffing, the only clear way to meet demands is to increase the efficiency of practices. There are moves in place to do just that. Health Minister Jeremy Hunt has put in place plans to turn the NHS fully paperless by 2018. That means a substantial shift in the way GPs go about their business and the way administration is handled10. He believes that IT has the potential to save the NHS £4bn as well as reducing the burden on already hard-pressed members of staff.

Reduces the time to treatment, with more patients treated successfully in the community

Reducing Workload On top of this, the NHS is looking to reduce the unnecessary workload of GPs. One of the key areas to come under fire is the referral process. An audit of referrals carried out by a CCG found that approximately 25% of all referrals were not necessary. According to the study, 15% of referrals were inappropriate and could have been handled in primary care. A further 8% were made

www.kinesisgp.co.uk +44 (0)7735 052905 @kinesisGP

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Health Minister Jeremy Hunt has put in place plans to turn the NHS fully paperless by 2018. That means a substantial shift in the way GPs go about their business and the way administration is handled

ENSURING APPROPRIATE REFERRALS IS A TEAM EFFORT

before the condition had been fully explored and 1% were classed by the report as ‘bonkers11’. The report is clear about the biggest culprit – busy practices. GPs have little time to spend with a patient and when there’s doubt, it’s tempting to schedule a referral. However, this takes time and comes with a cost. There have been moves to reduce these numbers, but, in themselves, these can be controversial. In 2015, the BBC reported that doctors were being actively paid to reduce the number of patients being sent to hospital. Nine clinical commissioning groups were offering GPs incentives not to refer patients. In one incident, Birmingham CCGs were found to have been offering GPs £11,000 to cut referrals by 1%12. The move was described as ‘misguided’ by the BMJ. As one letter from a doctor to the BMJ put it: “There is no such thing as an unnecessary referral.” According to the writer, referrals falls into two counts: “Either the GP knew what he/she was doing and the patient needed to be seen, or the GP did not know what they were doing and the patient definitely needed to be seen.13”

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The Doctor’s Dilemma Reducing referral rates can make economic sense, but it comes with a risk, which brings us back to our Daily Mail headline. Any move to reduce referrals runs the risk of a patient suffering as a result. The challenge is to reduce referral rates without taking a risk with the health and safety of a patient. The solution may come in the form of technology. Several web-based systems are becoming available which make it easier for a GP to confer with a consultant. This can improve the care and support given to a patient without taking up too much time. Any new technology may meet with resistance. Doctors may be comfortable with existing procedures – they may be unsure of whether or not they can trust any innovation. However, as these products become increasingly available, they are demonstrating their worth with real life case studies. They offer a best of all worlds proposition: saving time, money and lives – all in the same package. Anything that does that has huge value for an under pressure practice.


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The Battle Against Referrals Jo Roth, Staff Writer Referrals are increasing and the NHS is under strain. To meet this challenge, managers are introducing a range of measures to make them faster and fewer.

The NHS has long been locked in a battle to improve the referral process for patients. The challenge is simple – to improve patient service by organising more prompt and efficient referrals; and to reduce the strain on waiting times. The solution is far from straightforward. While much is already being done to expedite the referral process by moving into the digital world, there are gains to be made in reducing the number of times a GP needs to make a referral. Improving the Process According to a paper by the Kings Fund14, approximately one in 20 consultations result in a referral. It says that, the ideal model of a good referral would look like this: •N  ecessity: patients are referred to consultants only when they need to be. •D  estination: They are referred to the correct place. •P  rocess: The referral process moves quickly and efficiently. However, the same paper goes on to identify significant “scope for quality improvement” in each of these areas. There is wide variation in the rate of referrals, it says, and inequity in the quality of the referral process across the country. This could be improved with educational interventions, guidelines, the use of metrics and financial incentives. That last point has been the subject of some controversy in recent times. An investigation by Pulse found that CCGs were offering rewards of between £6,000 and £11,000 to practices which reduced the number of unnecessary referrals, but that met with a predictable backlash: Maureen Baker, Chair of the Royal College of General Practitioners said: “This is a preposterous idea. It is deeply insulting and demeaning—as well as being highly unethical — to suggest that offering GPs money will change the way in which we care for our patients.15” Such a blunt approach has clear risks. For example, in 2013 doctors came under fire after a league table showed they referred fewer than half of patients who were later diagnosed with cancer within two weeks16. Doctors also leave themselves open to accusations of a conflict of interest, which has sparked the rise of third party

Saving Referrals through Clinical Dialogue

referral services. These kick into action once the decision has been taken to make a referral. The third party then manages the referral discussion with the patient. The government hopes the service will save money by reducing outpatient attendance and also ensure patients are given the most appropriate choices for their requirements. The government also believes it can reduce outpatient attendance and save the NHS money. However, there is little clear evidence whether these strategies are successful. A three-year study between 2012 and 2015 suggested referral management services had failed to reduce outpatient attendance and had instead pushed up costs. The study analysed one group of practices which used referral management and one which did not. It found no significant change in out-patient attendance and, indeed, one which used a service reported an increase of 1.05 patients per thousand patients17. According to this evidence, therefore, the net effect of referral management has been to increase costs while also undermining doctors18.

Faster Referral The main thrust of NHS strategy so far has been to make the referral process faster and more efficient. Traditionally, referrals have been made by filling out a referral form and sending by second class mail. Now, though, the NHS is transitioning to a digital referral process, which takes all this activity online. At present, 50% of referrals are made electronically and the government hopes this will increase rapidly over the coming years. It aims to hit 60% by September 2016, 80% by 2017 and 100% by 2018. However, there is a problem. GP practices can be stuck in their ways and reluctant to make the move onto new digital technologies. Once again, their solution is to use financial incentives – £55million which has been set aside to encourage doctors to make the change. Giving their reasons, Beverley Bryant, Director of Digital Technology, said: “For a long time our first class healthcare system has been let down by outmoded systems where patients are referred to hospital by second class post. We have a duty of care that extends beyond providing

Reduces referrals and substantially reduces referral costs

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Web-based clinical information systems can give doctors access to information and advice without the need for a referral

CLINICAL DIALOGUE BETWEEN PRIMARY AND SECONDARY CARE IMPROVES TIME TO TREATMENT AND AVOIDS UNNECESSARY REFERRALS

effective treatments. We must also provide an effective patient experience that ensures patients feel reassured at a time when they are most vulnerable.” The benefits are obvious. Using the system, doctors can instantly book an appointment for their patients and choose a date. Rather than having to wait days for the process to run its course, a patient will be able to leave the surgery with a time and date for their appointment. As well as expediting the process, it can also help with attendance. According to research from the National Audit Office, patients are 50% less likely to miss an appointment if they have chosen the time themselves. The NAO believes that reducing missed appointments could save the NHS £51million each year19.

The Potential of the Web It is curious that, in an age in which our lives are increasingly run by high tech digital technologies, the health service seems to lag behind. Digital technology can play a transformative role in saving money and improving

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services, but the NHS is only just beginning to scratch the surface of what technology can do. A number of new digital technologies are coming online designed to make the lives of GPs a little easier. In particular, web-based clinical information systems can give doctors access to information and advice without the need for a referral. These can connect GPs with consultants and experts who can help with a diagnosis. This method can assist in those instances where a doctor is unsure whether a referral is necessary and wants more information. Without it, the temptation would be to play safe and make the referral. By quickly accessing information a doctor will be able to place a hold on such an order until he or she is certain it’s needed. Systems such as these are in development from a number of providers around the world. Their use is still in their early stages but early figures suggest they are having some success. They will do what no approach has yet managed – reduce the number of referrals without risking the safety of patients.


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How to Improve Your Referrals James Butler, Correspondent GPs can take advantage of a growing number of services and options to improve the way they make referrals.

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EFERRALS ARE vital for everyone. For patients they can make the difference between life and death; for taxpayers they can be extremely expensive. Referrals can cost the NHS £15billion each year and that figure is rising. Figures from Cancer Research suggest that cancer referrals had increased by 50% over the past five years20. With the NHS under mounting pressure to control expenditure, GPs are being asked to look at ways in which they can control referral rates. However, this has to be done safely. Failure to refer a patient can come back to haunt a GP. For example, in 2012 a Birmingham Coroner criticised doctors for their ‘gross failure’ to send a 15-year-old girl for further tests. GPs attended the girl nine times before finally sending her for tests. That referral failed to adequately state her medical history, and, sadly, she passed away21. From the perspective of the patient, the thought that a GP might be reluctant to refer you because they are worried about the cost, is toxic for trust. The question is this: can the NHS reduce the rate of unnecessary referrals without adversely affecting the quality of care? It’s a far from straightforward question; for every outpatient referral which proves to be a red herring there is another which catches a potentially fatal condition. It’s a delicate balancing act that the NHS is constantly trying to manage.

Factors to Consider As doctors look to improve their efficiency, firstly they need to identify potential areas for improvement. One way to do this is to benchmark against other surgeries. This is far from an exact science as referral rates differ significantly from place to place depending on factors such as individual knowledge, patient pressure and composition of patient lists. For example, those areas with a higher proportion of older people might expect to see a higher referral rate as more patients arrive with complex cases. Equally, surgeries in more deprived areas may expect to see more conditions requiring expert appraisal.

It pays to conduct a full audit of referrals – looking for places where rates might be higher than expected. The CQC highlights the example of a clinic which conducted a review of its referral rates and noticed a higher than expected rate of referral among elderly patients22. They were able to assess their referral procedures to ensure they were timely and appropriate. The result was a reduction in the rate of unnecessary referrals to hospitals, without impacting on the quality of patient care. GPs should also welcome feedback from specialists on the quality of the referrals they have made. This can create a feedback loop which is mutually beneficial for all parties – while GPs can benefit from specialist advice, the specialists themselves can also gain learnings from general practitioners. There is some resistance to this approach from all quarters. There is a natural reluctance to invite feedback – a fear that doing so also invites criticism. Specialists themselves are often reluctant to offer feedback for fear that it could add to their already hefty workload. The key for doctors and practitioners is to embrace this as a chance to learn and improve. One option which has been successful is to encourage interventions such as workshops or training days run by specialists which give an opportunity to instruct GPs in more detail on the referral process. The Torfaen Referral Evaluation Project in Wales helped to reinforce the value of peer learning23. The intervention involved weekly practice level referral and review meetings and six weekly cluster meetings including consultant feedback. Referral rates in emergency and orthopaedics admissions reduced by 50%, with patients being directed to community based alternatives; better referral letter content; greater awareness about the use of referral guidelines and a reduction in referral variation.

Getting Information

Saving Referrals through Clinical Dialogue

Enables clinical dialogue and education

www.kinesisgp.co.uk +44 (0)7735 052905 @kinesisGP

Consultant feedback and information can, then, be critical. GPs serve as the gatekeepers – the WWW.PRIMARYCAREREPORTS.CO.UK | 11

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GPs serve as the gatekeepers – the reason they schedule referrals is that they cannot always know for certain whether a condition needs specialist attention

EXPERT ADVICE IN CLINICALLY MEANINGFUL TIMESCALES ALLOWS GPS TO MAKE THE BETTER DECISIONS

reason they schedule referrals is that they cannot always know for certain whether a condition needs specialist attention. If they can access advice from a specialist, they may often be able to avoid a referral altogether – or ensure the patient is referred to the most appropriate destination. Online clinical information services do offer a way to access this information. They can connect GPs with specialists to get advice, information and support. They can provide quick and easy access to experts, keeping GPs at the centre of the decision making process and can also build relationships with key medical specialists which, in turn, can deliver a number of key lessons for GPs. The NHS itself manages to save money and reduce time wastage. For experts involved they offer a way to share their expertise quickly and efficiently and to avoid wasting time and effort dealing with patients who have been referred needlessly. However, as with so many systems such as these, they are not all created equal. Some are

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better and more suitable than others. The key is the reach and nature of the contact they have with relevant experts – and, in particular, the speed with which doctors can access information. This can vary from option to option with some returning results within 24 hours and others taking much longer. It is also important to view this for what it is – information can only be advisory – providing another string to a doctor’s bow and allowing him or her more information from which they can make a diagnosis. It is not a definitive answer. All in all, there are several ways in which GPs can help to improve their referral process and, by so doing, help to alleviate the pressures on the NHS. So far, most of the efforts have focused on accelerating the process and, while there is plenty of scope for gains, doctors can also reduce bottlenecks by avoiding some referrals altogether. Digital technology has already played a transformative role in many areas of business. The time has come for the health service to truly embrace the many benefits it brings.


IMPROVING THE EFFICIENCY AND EFFECTIVENESS OF THE REFERRAL PROCESS kinesis-skyscraper.pdf

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Healthcare and the Digital Future Tom Cropper, Editor Digital technology has revolutionised the business world and now it promises to have a similar impact on health services.

I

F THERE is one thing that has had a greater impact on business over the past 20 years than anything else, it’s the internet. Digital technology has made the world smaller and business faster. Even small organisations work on a much larger scale and connect with professionals or clients from around the world. So why does the health service remain so far behind?

Business Intelligence In a digital world, much of primary care procedures remain stuck in the past. Despite ambitious government targets to go paperless by 2018, many practices still carry out administration by hand. One potential area of improvement comes through the rise of business intelligence systems. This market is growing rapidly. Gartner predicts the Business Intelligence Market will grow by 8.28% over the next few years. In 2013 it stood at £14.4bn; by 2020 it could stand at £20.81bn24. Business intranet systems enable professionals to improve their engagement within the organisation. They facilitate the flow of information between colleagues and can help them collaborate. They’re a great way to reduce silos within an organisation – namely the idea that separate arms of a company are working entirely separately and often to completely contradictory goals.

Online Information Systems A similar concept is being applied to primary care in helping GPs to communicate directly with consultants. Using a web based clinical information system, doctors can post enquiries which specialist consultants then answer. It gives them more information when making a referral decision and, according to developers, should improve significantly the quality of referrals they make. In many cases it can avoid a referral altogether. If a system works as designed, all parties benefit. Doctors remain at the heart of the decision

making process; they can get quick access to clinical experts, can offer patients improved services and save money. Hospital specialists can expand their sphere of influence and use their clinical expertise more effectively. The system also enhances doctor/specialist engagement programs and can provide an additional source of income. Most of all it should lead to a reduction in the number of unnecessary referrals they see each and every week. That reduction helps CCGs by providing direct savings through a smaller number of referrals, reduced waiting lists, enhanced communication between primary and secondary care and improved governance through the rise of auditable and trackable advice. The most important issue of all, though, is how the process feeds through to patient services. There is always a strain between the health service’s goals of reducing waiting lists and improving efficiency, with the aim of delivering best quality care. A referral can often seem like the safest possible option and any attempts to reduce their number brings an associated risk to patient welfare. Online information systems are intended to ease that strain. They give patients confidence in the quality of their care as they are assessed instantly by experts; they avoid the trouble of organising another appointment with a specialist and it keep the process within the scope of those they trust. More and more CCGs are adopting online information systems. At Wandsworth CCG, for example, doctors use Kinesis, developed by Cloud2 to get advice from specialists within 24 hours. A doctor can be speaking to a patient; they can tell him or her they will be emailing a specialist and when that information will come back. It’s clear, transparent and fast. The system displays the status of the specialist. Green indicates they are online and will be available to answer instantly, yellow says they are online but not necessarily at their computer and red says they are offline and will reply later. If

Saving Referrals through Clinical Dialogue

Kinesis is a secure web-based cloud solution that directly links GPs to hospital specialists to rapidly gain expert advice on patient treatment option, as an alternative to a referral.

www.kinesisgp.co.uk +44 (0)7735 052905 @kinesisGP

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Online information systems are already demonstrating significant improvements in the overall healthcare process, but there is more to come

ROBUST DECISION SUPPORT THROUGH TECHNOLOGY IS BETTER FOR PATIENTS, GPS AND SPECIALISTS

a consultant is online, the GP can right click and choose ‘instant chat’. The system keeps a full record of the conversation, which helps auditing later in the process. If a specialist is able to help they may be able to deliver clear advice then and there without the need for a future referral. Kinesis served as part of a wider referral management program implemented in 2010. At the time, other CCGs were making moves to improve their referral process. But, while others chose a third party referral management process, which took control out of the hands of the GPs, Wandsworth chose a different route involving education, support and collaboration. They used peer reviews led by GPs, educational sessions from the nearby St George’s Hospital, monthly reporting, feedback and the Kinesis online information service. The results were: •A  high level of support from St George’s Hospital: Consultants showed a willingness to be involved with the program. • Reduced outpatient activity: Half of all advice sessions resulted in a saved referral. •S  aved money: Kinesis savings for the financial year 2012/13 were £22,385 (based on five months of activity. As of April 4th there have been 2113 advice requests with 1074 resulting

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in a saved referral – approximately 50%. This resulted in a cost saving of £183,105 to date25. The system is expanding. Since the beginning of the program, the number of consultants online has increased from five to 30; 75% of responses come back within 24 hours and the CCG is looking to expand the program to other nearby hospitals.

And the Future? Case studies such as these offer clear evidence of the return on investment these systems can deliver. Online information systems are already demonstrating significant improvements in the overall healthcare process, but there is more to come. These are in the relatively early stages of development and, in the future, we can expect them to become faster and more comprehensive. As they become established within the healthcare environment, more and more specialists will be involved with the services. Digital technologies such as these are not a catch-all solution. They work as part of a wider suite of services designed to deliver a major step forward for the NHS. As it seeks to achieve the difficult balancing act of saving money while also improving services, new technologies could play an increasingly vital role.


IMPROVING THE EFFICIENCY AND EFFECTIVENESS OF THE REFERRAL PROCESS

References: 13% during 2008/09 HES online; http://www.hee.nhs.uk/

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NHS Institute for Innovation and Improvement. Delivering Quality and Value - Focus on: Productivity and Efficiency. April 2009

2

Babies Needlessly Dying: http://www.dailymail.co.uk/health/article-3643229/Babies-needlessly-dying-mothers-harm-s-way-NHS-funding-battle-stopping-urgent-referrals.html

3

GPs at Crisis Point: http://www.telegraph.co.uk/news/2016/04/05/gps-at-crisis-point-as-new-figures-reveal-unsustainable-pressure/

4

5

ONS National Population Forecasts:

http://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2015-10-29#main-points

6

NHS Faces Biggest Financial Crisis: http://www.telegraph.co.uk/news/nhs/11921381/NHS-faces-biggest-financial-crisis-in-a-generation.html

7

NHS Providing Poorer Carer: https://www.theguardian.com/society/2016/feb/18/nhs-providing-poorer-care-as-funding-crisis-deepens-says-survey

8 King’s Fund Analysis Find Crisis in General Practice: http://www.nhsconfed.org/resources/2016/05/kings-fund-analyses-finds-crisis-in-general-practice

9

Doctors Consider Leaving Profession: http://www.mirror.co.uk/news/uk-news/gp-practices-say-half-say-7484000

10

Jeremy Hunt Challenges NHS to Go Paperless: https://www.gov.uk/government/news/jeremy-hunt-challenges-nhs-to-go-paperless-by-2018

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Up to a Quarter of GP Referrals Unnecessary: http://www.pulsetoday.co.uk/up-to-one-quarter-of-gp-referrals-avoidable/20007690.article

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GPs Paid to Cut Referrals: http://www.bbc.co.uk/news/health-34421115

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There is no Such Thing as an Unnecessary Referral: http://www.bmj.com/content/351/bmj.h6148/rr-1

14

Kings Fund Diagnosis and Referral: http://www.isabelhealthcare.com/pdf/Kings_Fund_Diagnosis_and_Referral_2010.pdf

15

Should GPs be Paid to Reduce Unnecessary Referrals: http://www.bmj.com/content/351/bmj.h6148

16

GPs Under Pressure: http://www.telegraph.co.uk/news/health/news/10504522/GPs-under-pressure-not-to- refer-patients-to-specialists-doctors-warn.html

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Referral Management Ramps Up Costs: http://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/referrals/referral-management-ramps-up-costs-but-fails-to-reduce-outpatient-attendances-find-researchers/20003258.fullarticle

GP Professionalism at Risk: http://www.gponline.com/exclusive-gps-professionalism-risk-referral-scrutiny-grows/article/1293466

NHS England announces ÂŁ55 Million Cash Boost to End Hospital Referrals by Second Class Post: https://www.england.nhs.uk/2016/03/hospital-referrals/

19

Cancer Referrals Continue to Rise: http://www.pulsetoday.co.uk/clinical/cancer/gp-cancer-referrals-continue-to-rise-as-services-become-more-strained-says-report/20007851.fullarticle

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21

Doctors Blamed By Coroner: http://www.ashfords.co.uk/doctors-blamed-by-coroner-for-failing-to-properly-refer-patients-what-are-your-legal-rights/

22

GP example, Reducing Unnecessary Referrals: http://www.cqc.org.uk/content/gp-example-reducing-unnecessary-referrals-hospital-older-people

23

Torfaen Referral Evaluation Project: http://www.ncbi.nlm.nih.gov/pubmed/20051193

24

15 Facts about Business Intelligence: https://www.matillion.com/insights/15-facts-about-the-business-intelligence-market/

25

Wandsworth CCG Case Study: http://www.kinesisgp.co.uk/Content/_KINESISGP/Uploads/Wandsworth_CCG_Case%20Study.pdf

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Notes:

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Primary Care Reports – Improving the Efficiency and Effectiveness of the Referral Process  

Primary Care Reports – Improving the Efficiency and Effectiveness of the Referral Process – Cloud2

Primary Care Reports – Improving the Efficiency and Effectiveness of the Referral Process  

Primary Care Reports – Improving the Efficiency and Effectiveness of the Referral Process – Cloud2