Value-Adding Approach to Lot 8 Service Delivery

Through supporting major transition programmes in health and care systems nationally and particularly across the South of England, we are experienced in working across organisational boundaries to develop pathways that consider the needs of people above the needs of individual organisations and systems. This is particularly evidenced in our work supporting Vanguards and STPs to co-ordinate care across the whole system and our support, review and benchmarking of elective demand management initiatives. We undertake broad and meaningful engagement with staff and partners (including the public, care homes and the voluntary sector) to inform and empower people to change. To provide system-wide assurance that people are treated at the right time, in the right place and by the right person, we apply robust measurement criteria that allow all system partners to monitor and evaluate changes.

Our own expertise is augmented by the experience of our partners such as Johns Hopkins University, Cerner, GE Healthcare Partners and Lightfoot, who bring extensive international experience of uniting whole systems to help them work together effectively. They will help to ensure that SCW stays abreast of increasingly sophisticated models, tools, and techniques for accurately forecasting and meeting system-wide demand and capacity requirements. Health and care systems gain value from our ability to support demand and capacity planning through:

Introducing Integrated Decision Support Hubs to effectively co-ordinate care, aligned to ‘channel shift’ and ‘discharge to assess’ models and underpinned by Cerner’s HealtheCare capacity management solution;

  • Bringing together real-time intelligence and informatics from across the health and care system and presenting it clearly, giving end users what they need, when they need it;
  • Being leaders in developing the national eReferral system and the demand management opportunities this offers;
  • Integrating demand management  and predictive analytics (supported by John Hopkins) to give system leaders forward control and insight, underpinned by the Lightfoot’s ‘Signal from Noise’ integration expertise; and
  • A legacy of supporting five major interoperability programmes across the South which evidences the capability of our digital transformation team to expertly merge these systems to create a seamless whole.

The breadth of our capability and our supply chain of expert partners allow us to provide a ‘one stop shop’ service for an integrated health and care system, reducing support overheads and simplifying accountability for delivery. 

The case study that follows this response describes how SCW worked with referrers and secondary care providers to address real and perceived barriers that were preventing achievement of referral to treatment targets. It demonstrates how, after concepts have been developed, tested and proven, we support spread and adoption at scale to deliver tangible system-wide benefits for patients and service users in primary and secondary care.

Extended Case Study: Managing Elective Care Referral Activity in Somerset

SCW provides referral and demand management services for Somerset CCG. As an agile response to increasing financial pressure in the system, we initiated a programme to deliver savings on elective activity. While it was not our intention to reduce elective referrals explicitly, we expected that reductions in demand and activity would be a natural consequence of the improved system we planned to deliver. Working closely with the local elective care system and the eReferral System (eRS), we developed a programme of work for Somerset that included the following components:

 

We collated, analysed and benchmarked information from the eRS and identified significant referral variation between GP practices of similar demographic make-up. We compiled ‘GP Practice Packs’ to explain the findings to GPs and co-developed action plans for ‘high referral practices’ with CCG commissioning leads and GP Elective Care leads.

At the same time, we monitored and analysed usage of eRS Advice and Guidance (A&G) functionality across Somerset. We observed significant variation in how GP Practices used A&G and a strong correlation between high usage and low outpatient attendances. We subsequently worked with commissioners and providers to expand A&G usage; expand the specialties for which A&G is provided; and consider whether to mandate A&G within referral pathways.

To embed and sustain changes, we trained members of our referral management service to visit GP practices to engage with clinicians, Practice Managers, and (crucially) medical secretaries, who play a pivotal role in elective referral systems. The Field Force are experts in the operation of referrals at GP practices (including EMIS and other practice system processes), and the guidelines and systems in place within Somerset to manage referrals. This team ensures that all practice personnel involved in referrals get the support, training and communications they need from the wider system.

Somerset STP has been closely tracking referral demand. Most of our activity has been concentrated around Taunton and Somerset Trust (T&S) in west Somerset. From a reported growth in GP elective activity, T&S is now reporting an annualised decline of up to 9.3%, which is continuing at a more constant 7.1%. We have spread learning to the east of Somerset in Yeovil District Hospital (YDH) where GP referrals here are now declining by 3.8% and expected to increase. We have now created a ‘weekly dashboard’ of elective care bookings so that the STP can track all referrals and identify shifts in patient choice. This live information can be interrogated both to specialty and sub-specialty level. We are working closely within the Somerset STP to enact the 10 steps of the national Elective Care Transformation Programme. To support consultant use of the eRS A&G functionality in providers, SCW created a bespoke app that consultants could use to access some of the functionality not provided nationally. This includes automatically populating a fully formatted A&G response that can be shared with the patient. This software proved popular with clinicians and has been shared with other systems across southwest England. In May 2017, of the 9224 referrals and 1736 A&G requests from Somerset GPs, 688 (40%) resulted in ‘no further referral action’ being taken, and audits have shown this is a sustainable change. 

Our Field Force is now working with a group of practices to test whether mandating the use of A&G prior to referral improves outcomes further. We are also supporting Somerset to develop a wider strategy for A&G and facilitating discussions to resolve areas of duplication of A&G, to ensure that, for any specialty, it is just offered once, by one provider in the system, rather than by multiple providers. Once appropriate guidance is approved, we will make amendments to the A&G support app.

When I first heard that the CCG had commissioned SCW to run a Referral Management Centre, I was concerned that it would have a narrow short-sighted focus on reducing GP referrals through putting criteria and barriers in place, making the life of GPs harder, the care of their patients poorer, and restricting access to secondary care leaving primary care carrying the can. However, happily, nothing could be further from the truth. 

 

The RMC runs a number of ‘right minded’ initiatives which, in my view, focus on improving (rather than restricting) access to secondary care advice/support/management through diversifying the ways that secondary care can be accessed (think A&G, Consultant Connect etc.). The RMC also runs a ‘Field Force’ which goes out to practices to discuss their referral patterns, with the aim of identifying variation in referral rates and considering whether anything can be put into place to support referrers (education for example) to work differently. The result of this MIGHT be fewer referrals – but the key is that the aim is not to REDUCE referrals, but to ensure that only the RIGHT referrals are made and in the most appropriate way.

 

I believe that this is necessary and good work. Therefore, I volunteered to provide support and clinical input into the work of the Field Force. I stand to gain useful insights into their work and how to apply it to other practices.

Dr Will Harris, GP at Wells Health Centre and chair of the CCG Clinical Operations Group

How we work with Partners in Lot 8

Specifically within this lot, we will be working in partnership with Johns Hopkins University, Cerner, GE Healthcare and Lightfoot who bring experience of uniting whole systems to help them work together effectively. They will support us to introduce systems proven to support effective and ‘real-time’ care co-ordination and capacity management, namely HealtheCare from Cerner and ‘Signals from Noise’ from Lightfoot, who will also bring their experience from the Canterbury system in New Zealand to support live demand and capacity control.

Partners in Lot 8

 

Case Studies

To analyse South Somerset’s integrated care interventions (Complex Care Hub, Enhanced Primary Care), we worked with the University of York to conduct propensity score matching combined with a ‘Difference in Differences’ analysis (DiD) to establish detailed patient-level cohort case matching. Methodologically, this is analogous to a controlled before-and-after study and is considered a robust method for testing for an intervention’s effects in the absence of randomisation. Suitable controls are also being introduced to allow capture of the counterfactual – that is, what would have happened in the absence of an intervention. This relies on identifying one or more matched cohorts of control patients. The evaluation is ongoing, and we are reporting to the NHSE New Models of Care quarterly.

Commencing with paediatrics, we developed an A&G service for the Trust that now also includes gynaecology, orthopaedics, neurology, rheumatology, haematology, GI & Liver and endoscopy. Many consultants requested that all referrals went through A&G and this was accepted by primary care, primarily because response times are under 48 hours and GP practices receive a ‘care management plan’ if no referral is required (both of which are supported by SCW’s A&G app). These processes have been rolled out to other providers in Somerset and, on average, GPs are making 2,500 A&G requests per month (28% of all referrals). The average response time is 30.2 5hours.

): SCW created an app for Bristol GPs and practice staff, which allowed staff to create automatically populated patient letters as an alternative to nationally generated appointment requests. To improve service outcomes, the letter included contact details for triage services for different specialties, the latest RTT times for those specialties, and provider choice options. This enables patients to make a more informed and ‘reflective’ choice when booking. We have deployed this software in other systems and it is a key mechanism for future engagement and messaging to patients on topics such as self-management, activation and shared decision making. As a local bolt-on to the national system, it enables us to prompt referring staff on the latest protocols, preferred pathways, and the ongoing support available to patients for making informed choices. By making this information intuitively available for referrers, we have kept GP practices engaged in referral management, particularly when there is increasing pressure on their time.

SCW is at the forefront of developing and deploying interoperable systems, having led the implementation of leading programmes such as Connecting Care in Bristol and the Hampshire Health Record (HHR). In the future, real-time data for system management will be sourced through portals like the Hampshire Health Record Analytics solution (HHRA), which we describe below.

HHR is an integrated regional health and social care record that supports health and social care providers in Hampshire, Portsmouth and Southampton. It compromises longitudinal health and social care records for 3 million people, providing analysis and integrated insight into the whole population for 20 stakeholder organisations. SCW is working with the University of Southampton (USH) to develop the HHR so that it supports the improvement of patient care by generating insights and facilitating research. 

SCW developed a robust predictive model to understand patterns of demand at Royal United Hospital and community hospitals for patients requiring facilitated discharge and patients held in higher settings of care than necessary. Our objectives were to measure bed and non-bedded capacity in the community; identify demand and capacity gaps, based on current activity levels; test variables in different scenarios (admission, length of stay, bed capacity, bed occupancy), and confirm the number of and reasons for delayed discharges. We built a comprehensive model that links data across acute and community inpatient systems and shows patient flow from acute to community beds (showing delayed discharge and discharge destinations). Whilst initially analysing patient cohorts within hospital, inpatient and community non-bedded services, the model was flexible enough to be replicated and used to model other acute and community patient flows.

SCW developed a live daily report for senior staff, lead clinicians (including the LMC) and care analysts in care organisations across Somerset. Our business intelligence services co-designed the report with system stakeholders, so that they could instinctively use it without reference back for clarification or extra information. Senior staff wanted access through their iPads for mobility, so the report was designed around a ‘portrait iPad orientation’ and delivered as a PDF, which allowed a natural expansion or magnification when used on an iPad. The report gave a clear view of daily A&E status for the four main acute trusts, before scrolling down to causal effects for any problem areas. 

As 111 performance was considered to drive a large amount of performance in the system, a screen was designed to put 111 at the centre with the destination of the 111 callers spreading from that central point. The report also includes daily information on 999 performance and ambulance handover delays; net patient flow, elective and non-elective bed utilisation, cancelled operations at each Trust; community hospital bed capacity (RAG rated and shown through mapping); and delayed transfers of care split by ‘NHS responsible’ and ‘social care responsible’. 

Through this report, we are providing a self-service solution for accountable officers and staff for whole-system delivery. After an initial investment in design and development, ongoing delivery is incorporated into the daily work plan of a junior analyst (Band 5) and represents only a short amount analytical of time each day to check before dispatch.

Using data extracts from national eReferral systems, SCW reports ‘as live’ on elective booking trends across all elective care providers (acute, ISTC, community-providers, and primary care). Drilling down to specialty (e.g. orthopaedic) and sub-specialty levels (e.g. knees), gives the system immediate sight of changes in provider demand and whether driven by changes in ‘overall demand’ or the’ mix between providers’. 

In a system were GP referrals are declining and providers are concerned about loss of income, this is a valuable tool that provides reassurance of market share and prevents competition complaints from independent providers.

Want to see more

Why not browse the entire SCW case study library ?

SCW Case Studies