NHS gooroo blog

Archive for August, 2010

The King’s Fund has just published a new report on referral management, and delivered a cold shower to the referral management centres that some PCTs have created to weed and redirect GP referrals. It concludes:

the greater the degree of intervention, the greater the likelihood that the referral management approach does not present value for money.

Or, as one triaging GP put it:

It gets back to individuals making decisions on other people’s decisions.

Not that everything is rosy in the world of GP referrals. When GPs were allowed to review their colleagues’ referral letters they were not shy about saying what they thought:

When we first started, some of the referrals were absolutely appalling, dreadful. Two lines, referrals of two lines, please see this patient with headaches, and we automatically rejected all of those…

and

I mean, I just couldn’t believe my eyes initially, the quality of referrals was just dire

Well, criticisms are always fun to read. But what did work? In the words of the King’s Fund:

A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective. …

Practice-based commissioning clusters and their successors, the GP commissioning consortia, are the obvious conduit and driver for peer review and audit.

In other words, don’t second-guess the referring GPs; but do work at a doctor-to-doctor level on improving their referral skills. This makes perfect sense. At the time of referral, nobody knows the patient’s condition better than the referring GP. If some GPs aren’t very good at referrals, then the problem is unlikely to be solved by inserting a layer of second-guessers (who have only the inadequate referral letters to base their decisions on). As the King’s Fund says:

any intervention to manage referrals cannot look at the referral in isolation but needs to understand the context in which it is being made

So full marks for the King’s Fund report, then? Very nearly. My slight disagreement is when they say:

any referral management strategy needs to include a robust means of managing the inherent risks at the point when clinical responsibility for a patient is handed over from one clinician to another (so-called clinical hand-offs)

I would argue that they accept the concept of the “clinical hand-off” too readily. Referrals should not be fire-and-forget, rather the GP should remain available as the patient’s advisor after the referral has been made. After all, patients must give their informed consent to every step of their treatment, and both the consultant and the GP have a role to play in informing them.

Recently I visited a highly-capable senior manager who has been doing a lot of work on outpatient clinics. I will spare blushes by not naming names, but this is in a major acute hospital. Here is a flavour of current practices (which the manager in question is trying to sort out):

• Patients are booked into clinics, not to individual doctors. When the day of the clinic comes around, the doctors turn up and look around as if to say, “Oh look, we have three doctors in the clinic today. What are we going to do with ourselves?”. Then they divide the patients up between themselves, with regard to the training needs of the juniors, but without regard to appointment times. Unsurprisingly, this means that some of the doctors are not always very busy.
• No clinic time is held back for urgent patients. When urgent referrals inevitably arrive, they are force-booked onto the clinic. If there is no time to fit them in, follow-up patients are cancelled (to avoid delaying routine patients who are subject to the 18-week target). The displaced follow-up patients then have to be rebooked urgently, because they must be seen within a specific time window, and so the whole problem repeats itself.
• Another reason that follow-ups are being displaced is that they are not regarded as high priority. Yet no assessment has been made of whether all these patients need to be followed-up in the first place.
• The hospital has a good procedure for approving annual leave several weeks in advance. When a doctor’s leave is agreed, it is immediately notified by email to the booking staff, so that they can block out that doctor’s clinic time. But they don’t do this right away. Instead they wait until a few weeks before the clinic, when of course patients have already been booked in and must now be cancelled.

There is more, but I think you get the general idea. You may also recognise that this is not the only hospital in Britain where this kind of thing carries on.

(deep breath)

At this point I would like to appeal to the sense of professionalism that, thank goodness, remains strong across the NHS’s medical staff.

The above tales come from a surgical clinic and, according to the Royal College of Surgeons’ guidance on revalidation (p.18), all surgeons must provide, as core information: “Audits of practice: This includes your non-operative work and audits about the process of care”. An audit implies that there is some standard against which the process of care is being compared, and it is difficult to imagine our featured clinic doing very well under any conceivable comparison.

So what to do?

First there is a question of will. The doctors in this clinic are responding to proposals for change with a stance of passive resistance. I can understand why; years of experience have taught many doctors that passive resistance is a rational response to impositions from above, because the NHS is prone to fads that go away if you wait long enough. However I would question the rationality of that response in this case. This is a very local issue. It is causing many problems that affect all parties: patients (who are messed around and delayed), doctors (whose time is wasted), and the hospital (which fails to meet its waiting time targets and is wasting resources). It surely makes no sense to perpetuate this when the solution is within the doctors’ own grasp?

Now to the practicalities, and here are the things the doctors could do:

1. Book patients to each doctor separately, not to the clinic as a whole.
2. Ensure that when referrals are triaged (on paper) for urgency, an indication is made about which doctors could and could not see that patient, so that booking staff can allocate the patient to the right doctor.
3. Review the practice of issuing follow-up appointments. Are there alternatives that might work better for some patients (such as a patient information leaflet, GP follow-up, or alternating a follow-up by a junior doctor with review by a senior doctor)?
4. Reserve the right number* of slots in each doctor’s clinic for a) follow-ups and other time-constrained patients such as ward discharges; and b) urgent patients who are referred at short notice.
5. Use good booking tactics* when booking new outpatients.
6. Work out the capacity needed* to achieve the hospital’s waiting time targets, and take the necessary action if it falls short.

Finally, should these changes be made gradually, or all at once? I would suggest doing them all at once, with the possible exception of reviewing follow-ups which could be done separately. They are all parts of a whole.

* These items are big subjects in themselves. See SimTrainer and the Booking Rules calculator for reserving urgent slots, SimTrainer for the best booking tactics, and the Booking Rules Calculator and Planner for working out capacity.

The European Working Time Directive (EWTD) is a massive issue for hospital doctors, so anything that leads to better use of doctor time is a bonus. In this post we’ll take a look at improving the utilisation and predictability of doctor workload in clinic.

Clinics are not always planned and managed in the most scientific way, and instead a variety of local customs and practices apply around the hospital. Also local rules are often unclear when it comes to handling events like urgent referrals, peaks and troughs in demand, late cancellations, and all the other sources of disruption.

As well as increasing waiting times, this inconsistency can also waste doctor time. If urgent referrals are frequently squeezed into already-full clinics at the last minute, then clinics will overrun, putting pressure on doctors’ overall working hours. If on the other hand slack is being left in the system “just in case”, or troughs in demand are poorly managed, then doctors may be left unproductive during gaps between patients.

You might even suffer from both evils. An overrunning clinic always overruns at the end, but the unproductive gaps can be anytime.

In situations where the waiting list comes and goes, such as an A&E department, or a clinic with a very short waiting list, it is understandable that doctor time cannot be fully utilised. But where there is a persistent waiting list, which is more usual for outpatient and admitted patient waiting lists, the goal should be to book patients into all the slots available so that every doctor’s time is used productively.

It takes a certain amount of confidence, and some very clear rules about how bookings should be managed, to make this work in practice. When we were doing our research into patient scheduling, we made it an axiom that the available capacity should be fully utilised, for the simple reason that wasted capacity is the worst sin of all, leading to longer lists and longer waits as well as wasting money. So even if the motivation for introducing better booking rules may be to protect clinical priorities or reduce waiting times, all the other benefits of full capacity utilisation come built-in.

What does full capacity utilisation look like in practice? It is worth realising that full utilisation is not the same thing as a full appointments book. Custom and practice may over the years have whittled away at the capacity being declared available. For instance, it may have become normal to reduce the number of bookable slots in each clinic, in response to incidents or practices that happened years ago. Or perhaps patients are being passed to juniors only at the last minute without regard to their appointment times, with the inevitable result that some doctors have gaps in their schedules.

Using capacity fully means being realistic at the outset about the time available. How long does each first and follow-up appointment really need in clinic? How long does it really take to enter notes for each patient? When does the clinic really start and end? How many doctors will we actually have, and what kind of cases can each accept? And not least, how many follow-ups do we really need to make provision for?

In answering these questions you may feel the tug of past compromises; occasions when this or that was done for a reason that was expedient then but long-forgotten now. Those compromises need to be put to one side, because the benefits of full utilisation are so valuable for training, productivity, and performance.

Being honest about the capacity that is available is likely to have consequences: we may find that the waiting list is going to either grow unacceptably or disappear, or that activity will fall out of line with commissioners’ intentions. That is the trigger for further honest discussions about the amount of activity commissioners are going to pay for, and the relationship between the waiting list and waiting times. Those discussions may be frustrating, but it is better than wasting the precious, rationed time of highly-skilled and expensively-educated doctors.

At the end of July the NHS Chief Executive wrote round with the new Service Reconfiguration rules. His letter formalises the four straightforward tests that the new Secretary of State wants applied to every proposed service reconfiguration:

support from GP commissioners;

strengthened public and patient engagement;

clarity on the clinical evidence base; and

consistency with current and prospective patient choice.

Unfortunately the straightforwardness ends there, and the letter immediately runs into the heaped sands of inherited bureaucracy. The four tests involve commissioners, the public, patients, and (tacitly) the providers concerned, so it is unsurprising that these feature prominently in the letter. You would expect there to be some other process, given the risk and money involved in reconfigurations, but is it really necessary for local commissioners to involve all of the following? In order of appearance in the letter the cast list is:

• Strategic Health Authorities (SHAs)
• Local Authorities (LAs)
• Local Involvement Networks (LINks)
• Office of Government Commerce (OGC) Gateway
• National Clinical Advisory Team (NCAT)
• Independent Reconfiguration Panel (IRP)
• LA Health Overview and Scrutiny Committees (HOSCs)
• Cooperation and Competition Panel (CCP)

The involvement of so many bodies invites a number of criticisms. It is centralising and weakens local decision-making. It delegates complex judgements to bodies who may be expert in their subject but unfamiliar with the local particulars. It causes delay. It confuses the process, and thereby pushes blame back up the system to the Secretary of State. It is expensive.

So expect further reform, as the Coalition Government sets to work simplifying and localising decision-making in the NHS.

Something else is odd, though, and this goes to the heart of the Secretary of State’s new approach. The covering letter says:

The Secretary of State has also made it very clear that GP commissioners will lead local change in the future.

If the Secretary of State wants a market in healthcare, then surely this is going in the wrong direction? In a normal market, customers don’t design products; companies do. So healthcare providers should conduct the market research and consult the stakeholders, and if that goes well then they can design and take the business risk on developing new service configurations.

To be fair, the Secretary of State only walked into his office a few weeks ago, and cannot be expected to reform everything all at once. But, as the evolving policy on service reconfiguration shows, he will have his work cut out to achieve more straightforward and local decision-making in the NHS.

On Friday the Department of Health updated the Procurement guide for commissioners of NHS-funded services. It is littered with the familiar dreary life-sapping injunctions about OJEU notices, procurement rules, and the need to review, benchmark, and consult with everybody in sight. But in the middle of it all, you can glimpse the future of NHS commissioning: the Any Willing Provider (AWP) model. The guidance says:

AWP may be described as an accreditation process underpinned by a ‘call-off’ contract (ie payment is determined according to patients’ choice of provider). AWP has been defined nationally in its application to routine elective care, but can be adapted locally to facilitate patient choice in other services.

…which of course is virtually identical to the wording in the March 2010 version, and a continuation of the AWP rules that were set back in May 2008. So far, the “Liberative” policy is identical to the “New Labour” one.

As often happens with policy innovations, the AWP model is aimed at routine elective care. Policy-makers don’t like messing with the hot stuff if there is a less-controversial area they can start in. But they did leave the door ajar for AWP to be used in other areas of healthcare as well, if local commissioners want to stick their necks out. And local commissioners should. The language in the guidance may be couched around patient choice, but it works for commissioner choice too and gives GP commissioners much greater flexibility when referring emergencies and electives alike.

The trouble with AWP is that it insists on using the NHS Standard Contract, which itself is still rooted in the old world of planning and performance management. What AWP really needs is a Standard Contract Lite, under which GP practices could refer at tariff or local prices but without needing to go through the laborious processes for agreeing detailed activity tables and performance indicators.

That would bring GP Commissioning closer to the world of the normal small business. A local firm of plumbers does not negotiate and agree lengthy annual contracts with each of its suppliers, specifying guaranteed volumes and bespoke performance standards. Instead it sets up accounts at Travis Perkins, Plumb Center and the rest, and pops in from time to time for pipes, valves and whatever else it needs. If one supplier disappoints on cost or quality, they favour a different one for a while. Minimum performance is taken care of by law, regulation, and standards.

Healthcare is more complex and expensive than plumbing, but in other respects the analogy holds where there is a choice of provider. In this spirit, the Procurement guide says for AWP:

As a minimum, potential providers must demonstrate that:

1) They are registered with CQC (or other relevant body) for that service

2) They agree to the tariff that commissioners are willing to pay

3) They receive no guarantees of volume / payment

So minimum standards are assured, price is fixed, and the activity plan tables in the Standard Contract are redundant. This should make the development of a Standard Contract Lite relatively straightforward; all that is needed is a minimum-content default wording for all the locally-negotiated elements in the contract (which in most cases will simply state “Not used”). Local commissioners could do this themselves, or the Department could save them the trouble by providing default wording for them.

Is that it? When Standard Contract Lites are in place for AWPs, can GPs buy care for their patients just as any small business manages its supplies? Not quite: there is still quite a lot of other baggage to deal with. Can you imagine an average GP being enthused about commissioning, while:

In addition, this guidance requires that commissioners also undertake the following as part of the procurement decision-making process

• Undertake Service reviews to identify areas for improvement and ensure alignment with commissioning strategy (eg QIPP)
• Apply benchmarking to existing services
• Use healthcare market analysis
• Specify relevant service specification, outcomes, KPIs and expected prices
• Engage early with providers, staff and representatives / Trades Unions to asses the potential impact / deliverability of the service
• Engage with service users local communities and other key stakeholders eg Health Overview Scrutiny Committees and successor arrangements …
• Have regard to any sustainable development aspects of the procurement.

This baggage had its place in large-scale bureaucratic commissioning. But it will be unsuited and unnecessary in a more normal marketplace, in which the real commissioners are referring GPs, and the risk of establishing a service lies firmly with the provider. When PCTs are leaving the stage, would they kindly remember to bring all their baggage with them?