The NHS Five Year Forward View and New Models of Care dominated proceedings at this year’s Health+Care, reminiscent of the show twelve months ago. One year ago, however, the key focus of the show was about enhancing patient choice: how do we as commissioners or providers ensure patients can access care where they want and need it? While patient choice remains an integral part of the NHS constitution, it is no longer at the forefront, and leaders are getting more serious about how they can increase efficiency and reduce demand.
This year’s show reflected this evolution. The underlying rhetoric was different. Phrases like ‘demand management’ and ‘greater efficiency’ were frequently heard in prominent talks, and more widely on the show floor. Historically, demand management has evoked negative connotations for those in healthcare, though perhaps not always warranted. Based on our own discussions it is clear that this move is not only warranted but also one that is pragmatic. It also had a significant impact on the nature of our referral management conversations. In particular, I would like to highlight two points.
Evidence alleviating concerns
A year ago, when we attended the show, discussions of referral management were well received but also met with an air of scepticism. The concern, as expressed by the people we spoke with, was that operating a referral management service was expensive – and there was limited evidence to suggest its value. The difference this year, it appears, is that the data has alleviated concerns.
Over the past 24 months or so, there has been a significant increase in the number of referral management services in operation (as revealed in our June Whitepaper). With 30% of CCGs now commissioning or operating a referral management service we now have access to a much richer data set. In many cases, the data indicates that where a referral management centre is in use it holds the number of outpatient appointments constant (although there are examples of reduction): this is no small feat considering population growth and demographic shifts.
A ‘shared’ problem
Previously when we’ve attended health shows our natural audience has been with CCG members and those operating a referral management centre. This year however we engaged in significantly more discussions with staff from large Trusts, and it is easy to understand why, with a number of recurrent issues being raised.
Trusts are receiving considerable volumes of incoming referrals. In some cases they do not possess the capability to offer the treatment or procedure referred for, consequently they must reject the referral. In some instances the volume of referrals for a certain speciality may be so considerable that it can take a number of weeks for the Trust to even review the referral, meaning a patient could wait two or three weeks just to learn that they no longer have a referral to hospital.
Another prevalent issue relating to demand is that of non-commissioned treatments or procedures. As CCGs (justifiably) tighten their financial grip it is more important than ever for Trusts to ensure that they are not conducting procedures that the CCG will not pay for. In each of the issues presented here a greater level of validation is required, and this can be achieved in a couple of ways.
Change is required
It is abundantly clear that something must change. Trusts around the country are at capacity, and although there are a number of community providers offering an appropriate alternative, take-up is still too low. Whether implementing a SPA to ‘screen’ referrals as they enter a hospital, or establishing a referral management service that processes referrals from primary care, the outcome is the same. Appropriate referrals, delivered or received at the right place, with considerable data produced – enabling greater demand management.
‘Demand management should be seen as one element of a broader commissioning strategy that maximises value from the NHS budget’ (King’s Fund 2010).