Christopher Moss and colleagues discuss the implementation of a referral management system in Abertawe Bro Morgannwg University Health Board
Health systems across the world face a major challenge in managing demand while ensuring the delivery of appropriate and high quality care. This is particularly pertinent for the NHS in Wales as it works to balance the delivery of high quality services for patients, while ensuring the effective use of its resources.
GPs make in excess of 700,000 referrals to hospitals in Wales for elective care each year. The management of referrals can attempt to influence referral behaviour and has the potential to support faster and safer patient pathways and to support appropriate and cost-efficient commissioning.
The Abertawe Bro Morgannwg University Health Board has an annual budget of £1.3bn and employs around 16,000 staff. The board is responsible for the provision of primary and secondary care hospital services for the residents of the county boroughs of Swansea, Neath Port Talbot and Bridgend and is the tertiary service provider for Wales and the South West of England in respect of burns and plastic surgery.
In addition to being a service provider, ABMU Health Board also purchases services for ABMU residents from a number of NHS Wales providers including the Aneurin Bevan, Cardiff & Vale, Cwm Taf and Hywel Dda Health Boards. Consequently a considerable number of ABMU residents access non ABMU provided services.
The Welsh Government has produced a suite of frameworks providing the strategic context that Welsh health boards work within, including:
- Designed for Life. This aspires to improve health, reduce inequalities in health and ensure quality, safe and sustainable services are provided locally where possible. The framework challenges the NHS to better manage demand at primary and secondary care level and identifies the importance of focusing on demand management “to reduce both inappropriate demands on primary care and referrals to hospital by maximising alternatives”.
- Setting the Direction. This challenges NHS Wales to develop and deliver improved primary care and community-based services for their populations, to provide services in such a way that an increasing number of people can be managed effectively in their communities, avoiding unnecessary hospital admissions and provision of high-quality organised services closer to home.
- Together for Health. This outlines the Welsh Government vision for the NHS by 2016 and challenges NHS Wales to improve patient experience through the provision of improved access to primary care, more services available 24 hours a day/365 days a year, and a greater range of local services.
Within this strategic context, the ABMU Health Board was keen to explore opportunities to actively manage the referral of residents to ABMU-provided services and away from traditional referral routes into neighbouring health boards.
There are a wide variety of approaches to referral management and the ABMU Health Board favoured a referral management centre principle on the basis of the ability to filter out inappropriate referrals, direct referrals to the most appropriate setting, develop a body of expertise and guidance about local services, improve referral quality and provide evidence to support commissioning decisions.
However, the limitations of this approach were also noted, including that overall costs could be increased, referrals could be misdirected in the absence of full clinical information, a barrier to closer working with GPs and consultants could be created and referrals could be delayed or lost in the absence of robust governance.
As a result, the board chose to develop a referral management system (RMS) as opposed to a referral management centre (RMC) on the basis that an RMC could generate significant additional costs for the organisation and be unlikely to present value for money.
The RMS was hosted within the ABMU planning directorate, with lead planning officers overseeing the development, implementation and operation of the process, absorbing this within their existing portfolio of responsibilities.
A number of principles for the operation of the RMS were established, referencing those developed by the British Medical Association:
- The prime purpose was to improve the patient care pathway, ensuring that it is not lengthened and delivers benefits for patients.
- The RMS approach was not to be driven by the desire to save ABMU money but would consider the effective use of resources.
- Active consultation and engagement with clinical colleagues in primary and secondary care to agree the process.
- Referrals to a particular consultant where it is clinically indicated would be supported.
- Any review of referrals would only be undertaken by clinically qualified colleagues.
- Robust clinical governance arrangements and audit to be established.
- An RMS policy, with clearly defined objectives, to be developed and circulated to all relevant clinical and non clinical colleagues across ABMU and external health boards.
Working within these principles, officers of the planning directorate undertook preparatory work prior to implementation in order to ensure a robust system was established for the management of referrals:
- The prime purpose of the RMS was established to actively manage the referral of ABMU residents to ensure that they are able to access the right service, in the right place, at the right time, provided by the right person.
- Meetings were held with GP colleagues across ABMU to develop the operating criteria (figure 1) and referral template for the RMS, obtaining endorsement from the ABMU clinical directors for primary care and the local medical committee.
Figure 1 RMS operational criteria
|Referrals to Cardiff & Vale and Hywel Dda health boards only||Longstanding clinical relationship relevant to requested treatment|
|New elective patient episodes (non-urgent)||Transport issues indicate patient would be better served by non-ABMU service|
|Referrals from GPs & ABMU consultants||Where support/social/family arrangements are in place and would be de-stabilised by movement of a service to ABMU|
|Services must be available within any location in ABMU||Where a cancer MDT decision is to send patients out of ABMU to a specialist service|
- Liaison with ABMU clinical directors to develop the process for clinical review of referrals with nominated clinical leads identified in each acute directorate within ABMU.
- Timescales for the processing of referrals agreed with GP and ABMU clinical leads with a mechanism to provide feedback to the referrer.
- In partnership with the ABMU patient experience involvement group, patient information leaflets were developed and circulated to all ABMU GP practices.
- Meetings with external health boards to inform them of the RMS process and request that any referrals received for ABMU residents not authorised by the RMS be returned to ABMU to be processed.
- A procedure for the operation of RMS developed and circulated to each GP practice across ABMU and to ABMU clinical directors. An electronic copy of the procedure, along with the referral template, posted on the ABMU GP resource portal hosted on the ABMU website.
Experience to date
The RMS became operational on 24 November 2010, initially focusing on new elective GP referrals for ABMU residents to Cardiff & Vale Health Board and Hywel Dda Health Board.
For the period the 24 November 2010 to 31 March 2012 the RMS has received 502 referrals for ABMU residents to either Cardiff & Vale or Hywel Dda Health Boards, authorising 327, redirecting 175.
In processing the 502 referrals, the RMS has gathered intelligence on referral patterns for ABMU residents that will inform the future commissioning intentions for ABMU Health Board.
In repatriating 175 referrals to locally provided services, the RMS delivered financial savings in excess of £250,000 based on a combination of full and marginal cost recovery.
Most importantly, however, is the impact of the RMS on the patient care pathway. The review of referrals received by the ABMU clinical leads has highlighted several important issues:
- Quality of referrals. At the commencement of the RMS there was not always been sufficient information contained within the referral. Feedback provided to the referrer has requested additional information to effectively process the referral and as the RMS process has become embedded, the quality of referrals received has improved.
- Referrals not always directed to the most appropriate location. Clinical review of referrals received determined that not all the referrals had been directed to the most appropriate specialty and/or organisation to receive treatment. In processing such referrals the RMS has ensured that the referral was forwarded on to the most appropriate specialty and/or organisation to ensure the patient is able to access the service in the right place and provided by the right person.
- Knowledge of local services – In processing the referrals it became evident that both GP and ABMU consultant colleagues had initiated referrals to Cardiff & Vale and Hywel Dda Health Boards without necessarily being aware of the local service options within ABMU. The feedback provided to the referrer by the RMS has consequently improved GP and ABMU consultant colleagues’ knowledge of services provided within ABMU.
The impact of the RMS can also be determined by analysing GP referral activity. The number of GP referrals for ABMU residents to Cardiff & Vale Health Board has reduced by 19 per cent from 2010/11 to 2011/12, the number of GP referrals for ABMU residents to Hywel Dda having reduced by 49 per cent from 2010/11 to 2011/12.
As GP referrals to Cardiff & Vale and Hywel Dda Health Boards have reduced, there has been an increase in GP referrals for ABMU residents into ABMU services of 10.1 per cent from 2010/11 to 2011/12. This increase may well be due to the educational impact of the RMS through increasing awareness of local service options within ABMU.
The management of ABMU residents within locally provided service models is a key objective of the ABMU Health Board.
In striving to achieve this objective, the ABMU Health Board was conscious that the introduction of an RMS could be perceived as being driven by financial motives and be viewed as an additional layer within the patient pathway resulting in increased costs, delayed referrals and interference with the patient/clinician relationship.
The implementation of the RMS is ongoing with the process subject to continuous refinement and review in order to ensure it adds value to the patient experience. Officers of the planning directorate are in regular liaison with GP and consultant colleagues to obtain feedback regarding the ongoing implementation of the RMS.
The scope of the RMS has recently been expanded to encompass all new elective referrals for ABMU residents to Cwm Taf Health Board with plans to expand the scope further to focus on new elective referrals for ABMU residents to Aneurin Bevan Health Board.
In addition to widening the scope of the RMS to include other health boards, the ABMU Health Board is also giving consideration to incorporating the Health Board’s Interventions Not Normally Undertaken (INNU) policy into the operational criteria of the RMS. The INNU policy outlines treatments that are considered to have limited clinical effectiveness and details criteria that patients have to meet before being considered for certain treatments.
By integrating the INNU framework into the operation of the RMS it is envisaged that the process will provide a degree of scrutiny on treatments offered by ABMU in order to ensure that NHS resources are used efficiently to deliver clinically effective services and not allocated to services and treatments with little or no clinical benefit to the patient.
Officers of the health board will continue to ensure that robust processes are maintained to manage referrals received for ABMU residents to access external health board services. Progress of the RMS will continue to be stringently monitored to ensure that the residents of ABMU have access to the right service, in the right place, at the right time, provided by the right person.
Christopher Moss is secondary care & specialised services manager, Maxine Evans is a corporate planning manager and Hannah Roan is a pathway and demand manager at Abertawe Bro Morgannwg University Health Board
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